Pediatric Abdominal Challenges in Non-Pediatric Hospitals: Pediatric Trauma...

Here in Evansville, uh, Indiana. And, uh, I labeled my, uh, my talk Pediatric Abdominal Challenges and non-pediatric Hospitals. Got no disclosures. And I, I think today really the goal is to uh discuss some of the challenges in taking care of children in predominantly adult hospitals because Um, you know, I, I think medicine is challenging enough, hard enough. There are enough articles out there to keep, keep track of your sub-specialty. Um, certainly when you have to think of, in terms of adults and children, two different worlds. And so, what tends to happen is people tend to just memorize one set of, of, uh, guidelines, um, potentially. And so if you're predominantly taking care of adults, that's Your, your tendency is to learn the adult literature and, and, and your behavioral patterns on children are gonna model what you learned from the adults. And so we'll talk a little bit about, about, uh, some of those challenges and some of the models uh in adults and how, how that affects, uh, taking care of children. And then finally, we'll discuss the adult CT triage data and how it affects triage decisions in children. So, we'll start with a case scenario here. 15-year-old male traveling at 30 MPH. He was restrained. GCS of 14 had mild confusion, small forehead abrasion, right zygomatic contusion. Uh, he had a fracture of the uh right distal radius, treated with a cast. Orthopedic surgeon said that was all that was needed. Complained of abdominal pain, hemodynamically stable with, uh, you know, heart rate in the 110s, so a little tachardic. Abdomen was soft, non-extended, mildly tender to palpation diffusely. The child did not have rebound, no guarding, and basically had faint seatbelt sign, um, to the bilateral iliac crest, uh, to the abdomen and chest. So how many people would pan scan this child is, is, uh, is the question, um, here. So Chris, do you wanna You put me to the test right away. I like it. I'll put you to the test right away. I knew where you were going. So, again, these are like the kind of vague ones, but he has a complaint of mild abdominal pain. I, uh, it sounds like he's tender, just tender to palpation, and then you're also saying he has a seatbelt contusion possibly. So this is a patient. I, I probably wouldn't have a lot of heartburn about getting a CT scan. And if you told me it was, um, normal, I, I still, I think, could sleep, uh, comfortably. Uh, knowing that he had, uh, you know, pretty some significant risk factors. OK, great. And um we just put up a, uh, a poll for those in the audience to kind of answer, answer that question, would you pan scan, um, or not? So we'll, as we go, we'll get some, uh, get some more information maybe on that. So go ahead. OK. So, uh, and I guess the question is, uh, this, this is a, this is a 15 year old, uh, what if, when those of you take care of adults as well, what if there's a 25-year-old male? Uh, my question to you is, Would you treat that individual different than you would a 15 year old? Uh, would you treat that individual different than you would treat an eleven-year-old or a, or, or an eight-year-old? And I think the answer is yes, and the answer probably should be yes. But what I'm gonna talk about now is what some of the, what the adult literature, uh, endorses and what the adult literature really talks about. And I think in looking at the adult data, uh, one of the more significant studies really, uh, in, in the systematic review and meta-analysis that has really shaped the adult data and adult literature and really has pushed more and more adult centers, whether they're level 1, level 2, or level 3, or non-designated, is, uh, pan CT scanning of, uh, certainly the more severe, severely injured adults, which then again translates into children. Um, uh, and, and, and then the, the, the argument really becomes, in, in the less severely injured, uh, individuals, do you pancy to those. But this, this is a very good systematic review and meta-analysis, uh, performed by Caputo, uh, back in 2014. And basically, they looked at, uh, most of the studies are retrospective. Uh, they, they have huge numbers and one of the, one of the studies and probably the one most commonly cited is Huber and Wagner. In 2013, they looked over 16,000 patients, but overall, you're, you're looking at a significant number of patients of almost 25,000 people. Uh, but they basically looked at patients into whole body CT scan, that's what WBCT is, and then selective. And as you can see, the ISS scores were fairly high. They were, um, 29.7 and, uh, about 2026. Um, which is, so one of the things about this particular paper that gets, that gets talked about frequently is that, uh, that maybe there's some selection bias and that the sicker patients were getting pan CTs, whereas, uh, the less sick patients were getting, uh, uh, just a selective CT scans. Um, if you look at the mortality rate, and, and that's what this paper is really looking at. And most of these papers, they focus on mortality. Uh, they don't look at length of stay for the most part, and they don't look at cost data, which we'll talk about in a little bit. But when you look at mortality alone, Basically, there was a a significant decrease in the, in the mortality, 16.9% versus 2.3% when you did the whole body CT scan versus selective CT scanning. And I think that really shook up the trauma world where, where people said, wow, those, those are some staggering differences. There are 25,000 people looked at uh multiple different studies, and they all basically, if you, you look down the line, they essentially all have the same findings that the sicker the patients are, The better off you are in doing whole body CT scans. Uh, and some of these papers were statistically significant. Uh, and the odds ratio, as you can see down at the bottom, um, overall odds ratio also shows the same thing. And so, uh, I think that in the adult world, that is, this really has shaped how we take care of adults, and that is, I think, a more, uh, this is where trauma has been heading, uh, as of late. And unfortunately, I think that's translating to children as well. Any comments on, on what your thoughts are here, Doctor Falcone or, or, or Chris? I, I mean, I think these are interesting data for the, for the adult population, but I, I, I worry about that translation because I think there's still different populations. We know our, especially the older adults, the, the geriatric adults are gonna have a lot more injuries, um. Than, than we see in our kids. We don't see very many of the significant chest injuries um that you see or the C-spine injuries that are, are seen in adults. So I think it's hard to totally translate this. I, I completely agree, uh, but, and I think that's my point that, that. When people, you know, uh, are, are learning and, and when you're, you, you have a, a hospital like mine where you don't have an isolated pediatric hospital, you have crossover and people tend to learn one way of doing things. Uh, why? Because it's difficult to learn multiple different ways for different age groups, you know. Are you gonna teach, uh, you're gonna treat senior citizens different than you are, your middle aged, uh, and are you gonna treat your pediatric population different and And those are the real challenges that I think we need to talk about today. Uh, but this is really the landmark paper that I think is really, uh, change, challenging, uh, and changing the way trauma is being looked at. Now, um, what the, some of the criticisms of that paper have been that all those studies, none of them were randomized. Now, this one study is actually randomized. It was, uh, published in Lance in 2016, and, uh, basically four hospitals in the Netherlands and one in Switzerland. Um, they, the average ISS score was about 20 and 19, so not quite as sick. Uh, again, these are all adult patients. Let me be clear about that. And their goal was to assess the effect of total body CT scanning compared with selective CT scanning on in-hospital mortality. And the reason I present this paper in isolation is because, uh, it came out after, uh, Cabuo's paper, and, uh, the, the, one of the biggest criticisms to Cabuo's paper was that, that's fine, but none of these papers are randomized. So, here's a randomized paper. And we can talk about uh this paper briefly. Uh, but I think one of the challenges of this paper is that if you look at ISS scores, overall, ISS scores were similar, but they were actually lower overall. They had about 35% of the population that had, that fell into the lower ISS scores. So it does not translate completely. Um, overall, they looked at about 1400 patients and sub-selected out about 540 in each, uh, category. Um, and if you, there, what's interesting about this paper is that it actually supports the notion that you do not have to pan CT scan everyone. If you look at all patients, this is every single patient that they looked at, there is actually no odds ratio difference uh between, uh, uh, between, uh, older, between pan CT scan and selective CT scanning. And so, now, uh, I, I'm interested to see what's gonna happen with the new wave, now that you have a randomized paper being talked about and, and that's out there in the literature now. Uh, there was actually a, a, a, a, uh, a, a systematic review, um, that was performed that included this paper, and they essentially ignored all the other papers and just included the findings from this paper because it was the only randomized study. So I'm interested to see what's gonna happen going forward, whether uh there's gonna be falling out of, of pan CT scanning versus uh selective CT scanning. But really what they found is that there is no statistically significant difference in in-hospital mortality uh in all patients that, that were severely injured when you had a total total body CT scan approach versus selective CT scanning approach. And the other significant finding is that the radiation dose was increased with total body CT scan. Uh, and in time to diagnosis was faster with the total body CT scan group. Uh, and I think this final point is really at the crux of a lot of the management decisions that That happen that occur on the front lines, meaning when you're seeing a patient, what is it most emergency rooms, their main goal is to reduce their length of stay. Patients want to get home. Uh, uh, a, a physician wants to see that patient, triage that patient, take care of that physician as quickly as expeditiously and, in a cost-effective, at least cost-effective way as possible, most effective cost way as possible. And so when you look at these triage thing, these triage models, um, everything kind of points towards total body CT scanning as being the most expeditious way of taking care of these patients. And by the way, if you can prove that they decrease mortality. Uh, then I think that's where the bandwagon has really piled on. So Roberto, can I ask you a question because you have it on this slide and, and Chris didn't bring it up and it didn't come up in the discussion, but you have this radiation dose was increased. In the total body CT group, and that's certainly something hot on the minds of of those of us that do primarily pediatrics is what's the lifetime risk of that radiation from those scans versus selectively. I think to be clear, none of us in the pediatric world are saying don't use a CT if it's indicated, um, but want to at least encourage thinking about that increased radiation dose for that child. So I think it's marked here in that study, so I just wanted to bring that up and, and get the, the thoughts on that. OK. Yeah, you know, I really think that uh radiation, uh, you know, it's interesting when you, when you talk about adults and you take care of adults, uh, radiation almost never comes into the mind of anyone taking care of adults. Now, when you start taking care of kids, uh, that becomes almost, uh, the primary focus to a fault, I think. I do think that the fear of overexposing children to radiation, um, Potentially increases costs and delays care in a lot of children because we are reluctant to Those of us who understand the data and literature with, with children, uh, we're reluctant to scan children because of the increased radiation. Now, I, I think that's, it's a, an important facet, but I think that that's one major facet that really, uh, detracts all, all of us taking care of children from moving forward more expeditiously in a more cost-effective way of taking care of these children. And by the way, if you believe the adult data, it shows that mortality is reduced, and so, I, I think. Uh, I, I, I like, I like, uh, Chris, I like your paper and that it shows that, that really there has not, not been any significant difference with mortality with children because I think that's, that's the most important thing. You're showing that there's no significant difference and if we can prove, obviously radiation doses lessened with, with selective CT scanning rather than total body CT scanning, and if we can now put into the model cost reduction, I think you have the trifecta that we need to prove that you don't, we need to stop doing pan CT scans on children. So, right, I have one, a couple of comments and then there's a question from the, the group. So, my comments are, one, I agree that there's a, there's a huge, there was a huge pendulum, pendulum swing to all about radiation and avoiding radiation and, and low as possible to the point that Either some kids that needed scans weren't getting them, or some people lowered their radiation dose that the scan was, was not usable because of the quality. So I think there's a little shift back, but, but we still need to be worried about what the right radiation dose is. I would also say. We, we at least did one paper looking at the teenage population and compared whether they were taking care of an adult or a pediatric group because the adolescents are often a group missed in a lot of these discussions and what we found a little bit to your cost question was That the outcomes were equivalent or slightly better at the pediatric centers, but with less imaging and shorter length of stays and shorter testing, which all would imply cheaper care. So I think you're right. I think we need more of that. There was one of the questions from the audience was in these studies, did anyone look at, you, you alluded to it a little bit that maybe it hasn't been, but separating out the Was there any difference between the 18 to 35 or the 36 to 55 and older? Were there different findings or did anyone look at things, um As a piece and then someone else kind of commented that pan scanning may take the thinking out of things, um, and, and in kids, we may need to kind of think a little more about those risks and benefits of the imaging. So any comments to those two things. Sure, uh, and so I, I, if you look at the individual papers that they, that the, uh, If you look at individual papers that are included in, in meta analysis, yes, they, they break it down by age. But when you look at Cabudo's paper and the latest paper that was, that was, again, another um um uh systematic review of the data that basically expanded on Cabudo's and included this paper that I just talked about, they, they do not break it down by age. They just say 18 and over, uh, and it includes everybody from 18 years of age all the way to You know, potentially 90 years old. And so, there are a lot of fallacies in these papers, but, but, uh, you know, I, I think when you're, when you, you know, I, I, I made a discussion before about uh having to Triage your, your care based on whether they're 50 to 60 or 60 to 70. At some point, you, you have to have algorithms that, that you, you can't be, you can't paralyze the system by having too many different algorithms for everybody because it makes taking care of patients very difficult. And so, I, I really think that that's what these studies have done. They've tried to incorporate all of, all of these, uh, age groups, uh, probably. and it does limit and hinder our ability to be able to take care of the individual age groups. Um, so, so, to answer your question is that, no, they didn't break it down, they did not break it down in the meta-analysis, but the individual papers did. I was, uh, uh, I think that was a great question somebody asked about the age. So, some of the conversations we've had, um, when I started kind of on this journey, uh, we, we also talked about cost and not just radiation. It was interesting, uh, we were sitting in a, a group meeting, the adult, uh, uh, group for peer review and the PES group, and, um, we both announced that we had a cost-saving, uh, plan. And uh my, my cost saving plan was to reduce CT and their cost saving plan was to reduce labs. So, yeah, that's the first comment that I would make is, uh, they're both cost saving, but I don't think that the, the savings and cost is probably equivalent because there's also the interpretation, uh, fee for, for the imaging. So I guess my question to you, and this is to kind of piggyback on the question about the age ranges, is, you know, well, a couple of questions. One, why would, why would this, uh, my, uh, concept not work in the, the healthy 18 to 35 year old patients? I wonder if we would see, uh, just as suggested, a more significant Um, impact on pan CT if, uh, if we went, uh, over age 40 or 45 and up, and then, uh, kind of furthermore, in your slide that you, you have up, um, maybe kind of alludes to this a little bit. I, I, I think when you say, you know, pan scan trauma patients, um, uh, you know, what, what, um, people may think is that everyone comes in the door, but what I wonder is that 0 to 15 ISS population. If, uh, if those were all, um, taken out of the PA scan algorithm at adult trauma centers, how many CT scans would, would we say then and, and I suspect you're probably not pan CTing everyone that comes in just based on their mechanism and really focusing on the poly trauma patient. The patient has obvious, you know, head or orthopedic. Uh, injury. And then my final, my final question is, um, how often does the chest CT change what you do on a patient with a, a normal chest X-ray or maybe just, um, a pulmonary contusion on the chest x-ray? How often are you finding that the chest CT really impacts your management? I, I think from a, um, clinical perspective, um, you know, being taking care of patients, uh, I, I agree with you that you can get most of the information. You need from a uh chest X-ray. Now, if you actually look at the data, um, they talk about a missed injury rate of 10 to 15%, and that's actually something that gets uh talked about frequently in uh Cuto's meta-analysis and some of the papers that, that, that's quote, quote, quoted within this study is that there's a, a potential significant number of missed injuries. Um, And, and so, that is one of the arguments that's commonly used and actually, I think on the next, uh, next set of studies that I will talk about, I have one more study to talk about, that that is up to 20% of missed injuries can be significant, can impact care. Um, and And it's only when they were doing these studies that they found out how many people were having missed injuries. And so, that is one of the arguments that's used. It's a very good point, and you're right, we're not pan CT scanning everybody, but one of the points that's used, particularly with your question is chest CT is that, you know, people are missing up to 20%, in some senses, up to 20% of uh injuries, uh, which you would not miss by a, a, by a pan CT scan approach. I don't necessarily agree with it, but when, again, when we're looking at the adult data, this is the stuff that's out there, and this is really what I think is motivating and, and, and changing people's habits, that's how they take care of patients. Um. And I'm sorry, you had another question. Well, the, the other thing I asked is, you know, what, what do you think about, um, stratifying based on age. But another comment, you know, that I, that I commonly hear is what happened to the history and physical exam and why, why are we doing fast if we're just gonna pan CT everyone? I, I completely agree. I think it's taking it, taking, uh, being a doctor. I, yeah, I, I think it's completely taken that out of the equation. I, I think you, the pan-CT approach. Um, I, I do think that it may have a role in centers, uh, and I say this as caution, in centers that may not have a lot of resources, uh, in centers that, um, that, uh, have limited, uh, individuals that take trauma or see trauma patients or see an occasional trauma from time to time. Um, uh, I, uh, you know, we don't like to see those patients referred to us with pan CT scans, but, um, uh, I, I, I, I think that Scanning everybody is a, a dangerous way because it does, it's a dangerous thing and it does take out being a clinician. Um, but by the same token, that may not necessarily be a bad thing in centers that don't have a lot of trauma experience and don't see a lot of, um, trauma patients. So Rina, those are great comments. I wanna let you finish. I also wanna recognize our, uh, well, I'll call him the, our godfather of Globalcast, Todd Ponsky, who, who challenged our, our people just pan scanning because they're lazy. I, yeah, I, I think two things. I think that is part of it. I think they are pan scanning because it's easy and they're lazy, and, and, and I, I think the other part of it is, uh. You know, CT scans are a sunk cost. Once you pay for that CT scanner, the rest of your, your variable costs are fairly low. Now, you can bill for each scan, uh, pretty good billing, and your radiologist get to interpret those, those images. So I, I do think that that is, uh, sort of one of the unspoken. Um, realities out there that on the front lines that drives people's behaviors, but you'll never see that on a, on an article cause that article will be shot down and, and, you know, that individual would be laughed at. But, but, uh, uh, when you're taking care of patients, I do think that those are some of the motivating factors. It's, you know, 2 o'clock in the morning, get a pain CT, I'll take a look at it. If everything looks good, you can send the patient home. I think that'd be a very easy thing to do on almost all your patients. But that's not the right thing to do. Uh, and I, I think that's a, a fantastic comment. Um, and, you know, hospitals make money on CT scans is the other driving force. OK, why don't we let you finish? There's some other questions coming in, but we'll discuss them as you get done here. So I won't talk about the limitations here. Uh, I, I think one of the problems with this study, one final thing is that there were about 46% of the patients that, that were supposed to be in the selective CT scan, scan group that actually crossed over into the pan CT scan. So they eventually, they got sequential CT scans that, that essentially became a pan CT. Uh, so, if you look at, if you pull up this article and you look at it, um, there are a lot of limitations to it. Now, let's take a look at another patient, uh, 12-year-old restrained head-on motor vehicle collision, uh, moving at 50 MPH, uh, low activation trauma. For us, it's a level two, no loss of consciousness. Uh, in the pre-hospital setting, the patient was brought in by ambulance. The patient had a GCS 15, no nausea and vomiting. The patient complained of abdominal pain, no back pain, no back trauma, hemodynamically stable, and this is sort of what we were talking about earlier earlier today, bilateral iliac crest, quote unquote seatbelt sign, but no seatbelt sign over the abdomen, uh, but tender palpation over the iliac crest and benign abdomen. And, um, I think we've already talked about, uh, this individual, uh, to some degree. The scan or not to scan, uh, but I think that, uh, you know, it's interesting. I, I think that that is a, it seems very obvious when you talk about it, but, um, I think that it is actually a quite challenging set of patients when they have that, you know, a little seatbelt mark over the, over the shoulder or bilateral iliac crest. What do you do with that patient? Can you send that patient home without a CT scan if they're not having nausea, vomiting? Um, so, I think those are important questions and this is an important subset of patients that we see. So can I just say that, that is the perfect patient, I think, to apply the prediction rule and get a chest X-ray and screening labs. And if they were tender over the pelvis, that may be the patient, you, you know, you would get a pelvicplafo on, but I, I would not knee jerk, get an abdominal CT on, on that patient. I'd, and, and our center, they are very attuned. I don't even have to say anything the residents would have already. Uh, ordered the, the studies cause that's our routine. I, I would, I would agree with Chris. I'm not, I, I mean, I get the sense that I'm. I don't know that I would say our residents are as in tune as Chris's cause he probably shares this, this, this study much more frequently with them than, than we have to date, but we certainly would have some residents uh who would flinch on that story and, and at least scan the belly, pro hopefully not the chest. We rarely scan the chest unless there's significant abnormality of the mediastinum on the, on the X-ray or concern there on the X-ray. Um, but I agree, I don't, I think iliac crest. Tenderness and seatbelt over your clavicle where it's supposed to be, I don't think I would routinely jump right to scanning. Now, Richard or Chris, if you don't scan that child and uh are you gonna admit every one of those children, uh, or would you be willing to send that child home from the emergency room without, only, with only a chest X-ray? Yeah, if I got a chest X-ray, you know, the pelvic plane film labs, and they're all normal, and we, you know, that usually takes about 1 hour or 90 minutes to get all that done, we usually will give them a PO challenge. If they can ambulate and they can drink and they're, they're not having any, um, symptoms of abdominal, you know, concern, we'll let those patients go home, particularly if they have a reliable, uh, parent. I mean, I think, I think that's the key. Yeah, go ahead, Rich. I'm sorry. No, I was, I, I would agree. I mean, I think I'd watch them for a couple of hours in the ED, um, and, and let, and let them eat something and send them home if everything else was normal, yeah. Yeah, I, I think we would too. We would, uh, you know, I don't think we need to scan this child, get a chest X-ray, um, and let them eat, and if they wanna take him home, I, I think we'd be OK taking them home even if they lived an hour away. Now, what if the child is vomiting at the scene? The child comes to you now, not vomiting anymore, but had 1 or 2 episodes of vomiting en route to the hospital. Would that change your algorithm? Richard Chris. So Parn study they actually uh emesis was one of the factors and they had a seven variable model. So I would say um emesis would probably make me think about it a little bit more, but again, I would, in this particular patient, if they had the exact thing that you showed me and they had vomited once at the scene, uh, you know, I think by the time they get there and they get labs and uh a chest X-ray and a PO challenge and they tolerate it, I still would think they can probably go home if it was 11 or 2 episodes at the scene and nothing subsequent. OK. I would be, I mean, I, I agree with Chris, I, but I would be, I would probably, I would certainly be more anxious with that kid than without the emphasis, and I think that's what Chris was saying as well. I don't know. I, I think it would, this would certainly now we're getting into, well, they had this emmesis, but what's their exam? If the emesis in their exam remains benign, I may still watch them, but it, it certainly piques my interest in, in scanning them. Yeah, but you, but this is a, a patient that, you know, you might say, OK, I don't feel comfortable sending him home, but I could admit him overnight and do serial exams. I, I don't think you have to CT that kid. Now, um, Chris and, uh, Rich, uh, I'll ask a question. Um, you both have residents and fellows. Uh, so admission overnight, uh, uh, forgive me for saying this, but I think it's probably a little bit easier for you than it is for, for the rest of us who, if we admit somebody overnight for serial abdominal exams, we're the ones that have to get up out of bed, examine the patient, and we don't have residents and fellows. Do you think that that Should affect or do you think that affects uh people's decision? Well, I'll say we don't have fellows, and when I say serial exam, uh, sometimes to the residents that's a suggestion. So the serial exam might be, you know, when I come in at 6 or 7 a.m. and, and do the exam, but there, there's pretty, um, good data in the pediatric literature. Certainly we don't. And tend to delay diagnosis of a small bowel injury or a colonic injury, but it's very well tolerated. So, you know, in this patient, I'm, I'm not too concerned that they have a solid organ injury that requires intervention. We would be more concerned about is, you know, a small bowel injury and, um, and still, you know, even if you delayed your next exam for 6 or 8 hours, I don't think that's gonna be harmful to the kid. Agreed, yeah, yeah, yeah, I agree. I'm glad to hear Chris's residents don't always go examine the kids all night either, so. In theory, now, what about mechanism? The car rolled over multiple times. Um, I think we've alluded to this a little bit, but, you know, uh, let's say the child is not vomiting, but the car rolled over multiple times. There was a, you know, 30-minute extrication to get the child out, same physical exam. Doesn't matter. Doesn't matter. Mm mm, I agree. I don't, I, I wouldn't make that much difference. I try to kind of teach our residents that. It's important to know the exam, so to have it in the back of your mind what other injuries you might be worried about, but to not let that drive all your triage or decision making. OK. See, I, I, I think that's very different with the adult data. Uh, I think mechanism of injury, uh, tends to override a lot of what gets done in the adult population. I think, you know, you've got a 60 year old, multiple rollover, uh, they have a little bruising here and there. Uh, I, I think the trigger for getting a CT scan in an adult would be a lot, a lot lower than it would be for a child. Yeah. Yeah, yeah, and that's, I mean, this is a great discussion. This is why, exactly why I wanted to put this together and have both of you here because these are the challenges um that we all face and then we face when we're talking to our adult counterparts to take care of kids and, and just as a reminder for everybody, you know, most kids are taken care of at adult centers, not pediatric centers after trauma. So, um, that's the audience if we want to really reduce scans and safely do it. Um, we need to quote, convince. You know, what the, what to do. Um, and, and that's a little bit of the, the chatter out there on our, on our chat for this. Um, you know, we've certainly had folks say it's, it's great that this rule is gonna be presented as East to try to start spreading that information, um, further to the general surgery or for the adult, uh, trauma surgeons because I think we can talk about it in pediatric surgery circles, but if it's not getting out there, um, and challenged in the adult population. Um, that's gonna be, nothing's gonna change for the majority of, of kids. Um, so, so I appreciate this. There was one question out here, um, that we didn't really touch on, um, and I don't know that I want to dive into it too deeply right now, but, um, the question about, are we scanning our adult centers a little more likely to scan because they're worried about getting sued, um, in the medical legal part of this, especially when it comes to, to kids perhaps. So, you have any thoughts on that? Uh, absolutely, I, I think that, you know, if you, if you are a practicing general surgeon in the United States of America, the uh, the reason you're, and you're taking trauma call, the reason your tra your uh malpractice insurance is, is gonna be higher than a person that does, uh, your malpractice insurance will be higher than the general surgeon that does not take trauma call. Uh, why? Because injuries get messed and, and I do think that, that is always in the back of your head. Um, and I certainly think that, and maybe, maybe I'm wrong in thinking of this, but I, I do think that a lot of people think this way, that as a, a trauma surgeon, adult, you know, uh, I, I, I'm, I'm not a pediatric surgeon. Um, I have no pediatric designation behind my name. It says pediatric trauma director. Um, I have more of a leg to stand on if something were to go awry or wrong with an adult, than, uh, than I would if something were, if I were to miss something on a child. And I do think that that is a fear out there, um, that, and I think that that's why people pan CT scanning a lot of kids that I don't, I don't wanna miss anything. I'm concerned about this kid. I, I wanna make sure I get everything. And, and I've actually heard this before from people. I just wanna make sure everything's OK. Uh, but I do think that that's what drives a lot of the behavior. I, I agree. Do you think, what, what are your thoughts, and I, I appreciate you being a little bit of the, the target here cause it's the challenging, you know, why do adult folks do this and, and us pediatric surgeons don't. I think there's a comment on the, on this as well that says, well, maybe the adult surgeons think we're all weird cause we're so worried about scanning kids all the time. And by your quick response, I'm guessing that's probably some truth to. That and there's probably some truth on our part, as we alluded to. The pendulum swung, swung really far to one side of, you know, limiting it radiation, limiting imaging, um, but I think there's probably a balance, as Chris's data would say, you know, there's probably a balance that you can certainly safely avoid scans and What do you think the adult folks will be more, become more comfortable as more data like Chris's um comes out and the PCA data comes out, um, cause that kind of gives you that leg to stand on from a, a legal standpoint. You say, I'm following, you know, Well-done studies and prediction rules, and I, because I, you know, I followed that and that I felt comfortable not scanning and there's a 0.1% chance, but that's, you know, that's pretty much with anything. There's at least a 0.1% chance that we're gonna miss something. Um, so do you think more time and more literature will help further convince adult surgeons that it's OK? See, I, I The issue for me right now is, um, I, Rich, you know, I buy into this, you know, you helped us, uh, really set in a, a radiation reduction program, and, and with your help, we've been able to, you know, set some of your guidelines and protocols and, and reducing our, our CT scanning. But, uh, what, what I find interesting is that the adult data and the pediatric data are going in two completely different directions. And I think that's probably we can sum up this, this webcast, um, in, in one way is that, that, that is really at the crux of it, that they're just completely going a different direction, pansy to all adults, whereas with children, uh, don't scan them because you're gonna give them cancer down the line. I mean, it, it, it, those are seriously the, the two overwhelming sort of uh views. Uh, and I think as more data comes out with, with children, absolutely. I, I think I certainly from a pediatric, and, and I think it is on the pediatric trauma directors, uh, to set the guidelines and policies within your hospital to, and to educate people to change their habits and that say, hey, don't scan every child, don't treat every child just like you would an adult. I, I, I do think it's up to us to change those behaviors and teach people and, and teach our, our colleagues and teach our ER colleagues and, and my partners as well. Um, and the more data that you, you bring out there, uh, I think gives me more leverage to influence my, my partners and, and my colleagues in the hospital. Absolutely. I think I, I mean, if you, if you look at what we presented, if the patient had none of the five variables present, you would have to do about 250 CT scans or scan 250 patients to find 11 intraabdominal injury. That's a whole lot of scans, you know, I do think the adult surgeons say, well, what if I missed something. And that would be how I respond to it. Well, 2, if you scan 250, you'll find, you know, something that the rule didn't pick up. So it's a, it's a pretty good, uh, rule. And then, you know, we were talking about mechanism. Both the Parn study and the study that we did, um, broke out mechanism and we even divided patients into kind of um, um, a made-up category of serious versus not serious injury and then serious injury included. You know, prolonged extrication, uh, you know, rollover unrestrained versus like the NBC that doesn't have that, and in both studies, the mechanism, uh, was not predictive of, of intraabdominal injury. So there is some data to say that, you know, um, you know, mechanism may be important, but it shouldn't be the reason that you decide whether to get a scan or not. So I, I just want to kind of in, in the time, there's a couple of things to, to point out. Um, there is in the chat, the, the website to follow to get your CME for those who participated. You certainly want to take advantage um of that. I also wanna kind of thank, certainly thank both of our presenters. I think this was a great discussion and, and the feedback is positive already. Um. Um, that this was a useful discussion and useful in pointing out, um, as, as you did, Roberto, the, the real crux of the differences, um, of where the literature is going, and I think there's certainly what I, one of the things I take out of this is we need more data to convince each other of what and figure out what the right thing is to do. Um, and there's probably opportunities on both sides from the adult literature to say, Why don't we think about using some of these prediction rules to avoid some pan scans, um, and from the pediatric side to say, OK, sometimes the CT is not so bad. Um, so I, I think there's certainly stuff to learn from, from both, and I think that's why I wanted, you know, hopefully we can continue to do discussions like this across adult and ed so we can, we can learn from each other and challenge each other to think differently. So, uh, with that, I don't think there's any other questions. There's a lot of thank yous.