Indications for CT Scan for Blunt Abdominal Trauma: Update Course 2017

Uh, I'm gonna spend my time talking about the 97% of the patients that we see following blunt trauma that are hemodynamically stable, so it's not quite as glamorous or exciting, but these are the patients that typically come into a pediatric trauma center and I cheated a little bit. I have two cases, but they're from the same vehicle and I wanted to use them to kind of make the point about who might benefit from a CT and who we can avoid it from, so. The first is a six year old male. He was a restraint, a restrained backseat passenger in a motor vehicle collision. It was reported as a car versus a tree head on at a high speed. Uh, he was on the passenger side in the back seat. Uh, there was no known loss of consciousness, and he presented hemodynamically stable en route. In our center we have a tiered trauma activation system, so he was the second highest level um on primary survey he had a patent airway. His respiratory rate was 27, Blood pressure 111/81, heart rate 131 on Broslow he was about 20 kg and had a GCS of 15. Pertinent physical exam findings. He had some mild midline, uh, cervical spine tenderness to palpation, and he had a noticeable seat belt contusion. I'll show you a picture of that. Uh, his abdomen was fairly soft, a little bit distended, but there were no obvious peritoneal signs, and he had the following, uh, imaging finding, which is this, uh, contusion here, uh, on the abdomen, uh, consistent with a lap belt, uh, type of mechanism of injury. The second patient was his sister also in the same vehicle. She's Uh, sorry, I went the wrong direction. She is an 11 year old female, uh, also a restrained backseat passenger in the vehicle. She was found slumped under the front, uh, driver's seat. There was a reported loss of consciousness. She was hemodynamically stable en route as well, again, a level B activation in the adjacent room. Uh, ABCs were pretty unremarkable. She also had some mild midline cervical spine tenderness and she was very distracted. She had several fractured incisors, uh, a lip laceration. Her midface was stable, and on physical examination, although she was, uh, very distracted, she seemed to have a normal abdominal exam. She did complain that she had some mild, uh, abdominal pain. Yeah, I think I'd like to point out for our audience that. That the seat belt side or or the abdominal contusion really should be a red flag for for everyone so a lot of surgeons may not see that very often but it really means that there's a tremendous amount of force that's been. Generated against the patient uh and so you really need to be vigilant that that child does not have an underlying abdominal injury, um, and sometimes it's very difficult to assess, uh, a bowel injury, uh, on CT scan with that you can assess the abdominal injury, but the bowel injury is difficult to assess. Absolutely. So I picked these, uh, two cases because obviously the same mechanism of injury. And I think questions for the panel, um, really is what is the routine at your center, you know, the goal of the a lot of the work we've done is to try to determine what population of patients don't benefit from abdominal CT so who, who, uh, do you believe, if you will, in, in getting labs and playing films in the trauma bay? Does that depend on activation level? How would you have, uh, triaged this patient? And then ultimately who is responsible at your center for determining what the evaluation is? Is that the ED physician? Is it the surgery resident? Is it the adult trauma surgeon that's at the bedside? Is it the pediatric surgeon? And we've had a lot of discussion about FAS this morning and, uh, I, I share, uh, a lot of the same biases with the panel, and I have some data to share about FAST in our experience, but do any of you use FAST to try to avoid an abdominal CT to try to, um. Find a patient population uh that you feel comfortable not uh scanning. I would like to. Uh, I, I don't either. I think the, the, the problem that we have is that it's not sensitive or specific, and, you know, and, um, you know, I, I don't think it ever will be until we get, um, um, IV contrast for it, and, you know, once, once we have, uh, one, and we actually just got IV contrast for, for ultrasound which may make a difference, but not, not right now. And then how about the, the question about labs and plain films, do you have a routine based on activation level and what, what is your standard routine for, for labs and imaging? We certainly have a routine. I can't quote off the top of my head what labs are in each at each level, but labs and X-rays are part of the initial evaluation. So, so one of the things that I find interesting is, uh, we have different tiers of evaluation. The lowest tier is really only evaluated by the ED, and we've actually noticed that those patients get more labs. And sometimes more imaging, which I, I don't know if you guys experience the same things in, in your institutions as, as well. So you know it's interesting because I think that we, we try to tailor who's gonna get imaging because we are very sensitive to the CT scanning and radiation and everything that goes along with that. The flip side is that I think that. In some ways we've gone almost so some almost too far because it's sort of like with the non-operative management right you still need to be able to recognize when somebody needs to go to the operating room and you see people hanging on by their fingernails to try like going to the OR is a failure or getting a CT scan is a failure. It can't be seen as a failure. It just needs, you just need to know which patient it's appropriate in. But we do labs and, and we, we base our scanning, you know, if you have a patient that you can examine and their belly is soft and benign and we, we do use the LFTs based on that old study from CHOP, uh, and I can never remember which one the AST is supposed to, which one the ALT is supposed to. Because if either one's over 200 we scan them. I'm gonna clarify that. I know, I know you are. I know you are. I did see a head, so I'm, I'm sort of giving you, you a little bit foreshadowing here, but, uh, you know, I, I do think that you can still treat the patient clinically, but we do have routines. OK, so, um, a little bit more information about the two patients, so. Uh, we, uh, rely, um, a lot on labs and imaging to try to assess some of these hemodynamically stable patients that have a, a seemingly reliable physical exam. So the brother with the seatbelt contusion, hematocrit was 37, white count 21, AST was 49, his lipase was normal. We didn't order a base deficit or lactate, and he had a normal chest X-ray. Uh, in contrast, the sister, uh, had an elevated AST. Her AST was 222, and she had some small pulmonary contusions on her chest X-ray. So, uh, this really gets to the heart of the matter. Who, who needs an abdominal CT? We kind of spoke about FAS, and I'll give some data on that. And looking at the first patient, is there time or a benefit to imaging a hemodynamically stable patient with abdominal tenderness and a seat belt contusion? Uh, looking at the second patient, is there any benefit to getting the screening labs to see if this is a patient potentially who could avoid a CT of the abdomen altogether? And then this is not one of the cases I presented, but what about the patient who comes in intubated that has a serious mechanism like a MVC or ATV. Uh, collision but has a normal physical exam, uh, on, uh, on your, on your, uh, evaluation. So what do you guys think on these two patients or the three examples? Who of these patients would you get an abdominal CT on? I agree with 100% on the seatbelt sign and the abdominal tenderness and a seatbelt sign. I would be very, very concerned about that. And I'll tell you, you know, the seatbelt sign that you showed is a, is a really bad seatbelt sign because it's not in the right place. Yeah, well, that's exactly right. I wanted to point, yeah, that's always the question because we sometimes will. Watch a seat belt sign if it's over the anterior superior iliac spine in the right place, may just be a, you know, and you can follow the patient because first of all, CT scan's not gonna be super sensitive for picking up the injuries, although our radiologists, I think, are pretty good at it. They'll see the focal ileus or something, but I, I, I, I really think that if it's in the wrong place. Then you're, can you go back to the image and just point out and you know that that image while you're going to find it, it's a great image by the way is why that's what all my kids' seatbelt sign would look like because every time I look back they got the lap belt where where head is up here and here is the umbilicus. So this is, um, closer to the costal margin here and you want your seatbelt sign over, over the bony pelvis. That's what, that's the way it's designed. That's why we have booster seats. Absolutely, would anybody have gone straight to the OR based on a seat belt contusion alone? No, OK, so I'm gonna give a little patients are stable though. Both patients are, uh, stable, and as I said, 97% of the patients in our, our study that I'm gonna mention were, were normal intensive. So, uh, hopefully this will project, but, uh, this patient, if I can get the pointer to work, there's some, uh, free fluid that's intermediate density. Uh, along the liver here this is the posterior wall of the stomach. There's, uh, fluid in the lesser sac, maybe a couple dots in free air in the next cut. The duodenum seems to have a hematoma here, uh, and there's some paracolic, uh, fluid in this gutter as well. This is just another cut of the same, uh, image showing the same findings. Our radiologist. Uh, interpretation of this other than what I've mentioned is that this patient in their opinion likely had a posterior gastric, uh, wall injury. Uh, I didn't couldn't agree with this, but certainly, uh, the findings were, uh, highly suggestive of, uh, a, uh, hollow viscous, um, injury. Uh, and then the second, uh, patient, uh, we did scan based on her elevated AST, and, um, she had a normal abdominal CT. Well, I feel better because I would have scanned both patients. Yeah, that's what I was gonna say. I'm glad you scanned both patients. OK, all right, so I'm gonna present and, uh, try to keep it to 5 or 6 minutes, um, some of the data that we've put together to help, uh, drive decision making about abdominal CT. Um, one of the things that's been most successful is we have a group, uh, the Pediatric Surgery Research collaborative. Several of the, uh, moderators here, um, have, uh, contributed. Uh, faculty members to this, uh, group, we have 14 institutions, uh, that have participated in the data collection, and, uh, mostly just want to thank all of them. Obviously, um, this is an important topic. Uh, there's a lot of pressure, I think, uh, now, um, in the, the trauma world to get um abdominal CT. And this is despite a low incidence of intraabdominal injury. Uh, less than 12% of the patients have an injury on CT. There's associated cost, of, of course we worry about radiation induced malignancy. Um, in contrast, um, 90% of these patients that are pediatric patients come into a non-pediatric center, and the standard at most adult trauma centers or non-trauma centers is the pan CT. There's actually a lot of literature out there, uh, on adult patients that suggest pan CT is safer. There are fewer missed injuries. It's more cost effective. So this is essentially what we're up against as, uh, pediatric, uh, providers is, uh, that the, um, the, the pressure is, is in the, uh, kind of the other direction. There are a lot of studies in the past that have tried to identify some combination of mechanism, history and physical exam findings, labs. That might um allow you to identify a population where you don't need to scan the patient and that was really the goal of our study was to come up with a prediction model uh that was very uh impactful in 2012, um, David mentioned the Parn Group. They put together a prospective study and, um, their primary outcome variable were patients with an intraabdominal injury that required an acute intervention. So they wanted to find or identify early patients that needed urgent surgery that might benefit from angio that needed a transfusion. They had a criterion of admission for 48 hours for IV fluids. To me that's not really an acute intervention, but it is a type of intervention, and they only used history and physical exam findings. This is a bit challenging, uh, as the providers doing this. There's a lot of subjectivity to just using history and physical exam. We actually, uh, validated their model and what we found was that it was actually very, very sensitive for injuries requiring acute intervention but it missed a lot of clinically relevant injuries, mostly solid organ injuries like liver and spleen injuries which we felt were important because it, it affects how we manage the patient even if we're not rushing straight to the operating room. So our goal was to come up with a prediction model. Uh, we also limited our model to patients that were within 6 hours of injury. That had not had a CT scan prior to transfer. These were patients that didn't have a focal injury to the head. They, these were truly blunt abdominal trauma patients, and we did a lot of, uh, fancy statistics. You can look at, uh, the paper if you're interested. It's in the Journal of the American College of Surgery this year. Uh, but we came up with a prediction model. These truly were patients that you would say had a severe mechanism of injury. Uh, almost half were motor vehicle collisions. At greater than 30 miles an hour, pedestrian or bicycle versus automobile ATV accidents, and what we found was very consistent with, uh, prior studies. Only about 12% of the patients had an intraabdominal injury and fewer than 3%, even when we selected for for more, uh, likely injured patients had an injury requiring acute intervention. And most impressively I think is this that the range between the four centers of CT scan ordering ranged from 4% of the population to 96%. Um, so that shows you, I think that there's a, a great opportunity for improvement in how we decide who needs a scan. Um, these five variables, this is really the take home point I think, are, um, the variables that came out in the prediction model AST greater than 200, an abnormal, uh, physical exam, an abnormal chest X-ray in the bay, a patient complaining of abdominal pain, or an elevated amylase or lipase. This identified a population. That, um, had a uh 0.6% risk of an intraabdominal injury and a 0% risk of an injury requiring acute intervention, so at least a third of the patients that we're seeing, potentially more, uh, don't need a CT scan even when we select for a more injured population. So negative predictive value is 100% for the. Injury requiring intervention and 99.4% for all injuries. So does that mean if you had all five of those were negative, correct, as, but if you had one of those five, you're not in that group. You're not in the very low risk population. So, and I'll show you kind of a breakdown of that. That's an excellent point, uh, Doctor Holcomb, so. This is looking at the patients by number of abnormal variables whether they had an injury like a solid organ injury most commonly or an injury requiring intervention, most commonly hollow viscous and as you went up in the number of variables that were abnormal, this is, this was the risk of uh an injury or an injury requiring intervention based on the number of positive, um, uh, abnormal variables, and those are the confidence, uh, intervals that were. Associated with that, so if you had 0 of those, you, there was no patient who had an injury that required intervention that required intervention. That's right. And there were only 5 that had, uh, an injury at all. They were mostly, uh, more minor solid organ injuries. So, um, to make it a little more clinically practical, we reordered the 5 variables in the order of information that you obtain as the physician. So the patient complaining of abdominal pain. If it's no or you can't assess based on being intubated or sedated, uh, the next was the physical exam of the abdomen, chest X-ray, AST, and abnormal enzymes. You still have the same 34% of the population, but, uh, if you wanted to look at a group that you might be able to observe, uh, or, uh, send home with, um, careful instructions, uh, what we found, uh, was a low risk, uh, group. Um, that, uh, made up 55% of the population with a less than 5% risk of any injury, uh, and a less than 0.3% risk of an injury requiring acute intervention. One of the, uh, things that has been criticized about this type of model is people don't feel like they can wait for labs to come back, and I think this would suggest, uh, that you certainly can wait, uh, even if it takes an hour to get your AST or your lipase. These are patients that, um. If stable and have a reliable exam that you can kind of park in the uh pediatric emergency department and wait for your labs to come back before you make a decision on abdominal CT and we've certainly send patients for a head CT sometimes without getting an abdominal CT. So the challenge from that are 21 is that you occupy the emergency room bay for an hour while you wait for labs, and we've done a lot of work to try to minimize the amount of time that patients spend in the trauma bay. Um, and then the second is if you send them for a head CT and then the labs come back positive, you have to send them back for the CT scan. Our scanner is is immediately next to the ER and we typically move them out of the trauma bay to a like a standard ER room, uh, to avoid tying that up. Um, in my opinion, saving the radiation and the cost of the CT is probably worth, you know, an hour of time, uh, but I think as was mentioned earlier, uh, it depends on your local resources, your comfort level, how busy your ED is, and. And I'm sorry to keep jumping in, but the other issue that always comes up is the radiation exposure issue, and I think that, um, sometimes that's more emotional than it is fact, you know, we don't know what the risk of malignancy is, and an entire talk about that up next, um, so we'll, we'll defer that because I want to get Chris go on. And I want to apologize to the virtual audience because they are lighting up with questions and we have not had time to get to them. Sure, I want to not discourage anyone. Please keep putting them because Chris will answer these. David will answer these. Mike, if it's a radiology, we will answer these questions. I want to do what we call rapid fire here, not much discussion, just a quick answer. Question is from, uh, and this is coming from Khalid Sharif. He says in a patient that has a seatbelt injury, they believe he should get oral contrast. It's the only way to rule out a perforation. That's the first question. Quick answer. I would say I, I disagree. I agree, um, that it can be difficult to identify patients with uh small bowel or colonic injuries. I don't think oral contrast adds to that. Um, I, I think our CT scans have gotten so good with the multi-slice scanners that typically there's evidence, it may not be free air, but there are subtle findings that would make you concerned for small bowel or other hollow viscous injury. There's also time, I think the data has shown. That there's time to do serial abdominal exams on patients and even if it's not clear on the CT, you may determine the patient needs further evaluation based on on serial exams. Mike, anything to add to that, or does that pretty much cover it? I would agree with that. OK. The thing is though, also that a bowel injury, although it's an injury. It is not a life threatening. And so even if you, you're unsure on like that scan, um, he showed if you're unsure if there's an injury, observing them for 6 hours or 12 hours and reassessing them, there's nothing wrong with that. You don't want to observe them for 5 days, but observing them for a few hours is a good way to be sure, if you will, that they need an operation. Uh, real quick, no, am I wrong to say this statement a missed bowel injury. A missed bowel injury, if caught within 24 hours, usually does no increased morbidity. Is that a false statement? There, there is a study, um, through ABSA a few years ago that supports that, of course, uh, I think the flip side of that is we don't wanna have delays, uh, in diagnosis or missed injuries. I think in 2017, particularly in the patient that I showed, uh, laparoscopy is extremely helpful. Um, if there's a moderate, even just a moderate amount of free fluid in a male and no, um, uh, hard signs of, uh, small bowel perforation, um, I, I certainly would consider laparoscopy in those patients. I think, uh, this is a different era than, you know, 20 years ago where patients went for DPL or immediately for a, a big laparotomy. We're pretty good at laparoscopy now, and it's very rare in my opinion. That you would miss something doing a laparoscopic exploration. OK. And then those questions that they're answering for each other. So I, I appreciate you guys all answering each other's questions. Lipase versusamylase, uh, I think the question was asked a while back about if you don't have, um, if we don't have lipase is amylase, good enough. Yeah, so in our study when we designed it we um allowed for either and when it says abnormal pancreatic enzyme it could be amylase or lipase in our institution they only do lipases most of the places I shouldn't say most, it was pretty evenly distributed between getting an amylase or lipase a few. Institutions got both. There is huge variability in the lab evaluation of these patients, and I think that was one of the most impressive findings is that we are all over the board in how we use labs and which labs we choose to, to use to evaluate. Great. All right, sorry to interrupt, yeah. Um, I, I just have two slides left and then there's, if there's time we could have more discussion, but basically, in conclusion we came up with a prediction model. Uh, I think it's, um, highly practical. Um, currently we're validating this. The P, the nice thing about the PCA data set is it's publicly available. We just submitted an abstract that was accepted to East and, uh, our, um, negative predictive value of this model and their data set. Uh, for all injuries was, um, very significant. So I think, uh, this, uh, going forward, the challenge will be to get people to implement this and to see if this is better than current, uh, practice. So that is our, our goal moving forward. Um, there are always questions about who to apply this to and again 97% of the patients are hemodynamically stable. There's a lot of variability amongst amongst institutions, so we can certainly. Uh, do better. I did wanna just show real quick a couple of slides. We did a subset analysis on FAST, and that was, uh, one of the topics. So, um, when we looked at FAST in these 2,188 patients. We compared FAST to CT and the patients that had both, which was 340 patients, and, uh, we found that FAST was very, very, uh, not uh sensitive, so it had a 27.8% sensitivity for injury and 44% for injury requiring intervention. So the negative predictive value was 76%, uh, which you might say, well, that's not that bad. But if you really break down the data, uh, and you look at solid organ injuries, so there were 42 liver injuries, fasts picked up 9 and missed 33, 33 liver injuries, so picked up about 1 in 4 liver injuries, that's probably because in kids you don't always get a whole lot of, uh, blood. You don't have a lot of hemoperitoneum always. Likewise for spleen, 30 injuries, 13 were positive, 17 negative. And when we looked at, um. The interventions again, uh, of the 14 patients that got transfused, 5 had a positive FAS 9 had negative holo viscous injury, it picked up 7 of 15, uh, and, uh, surgery, uh, it picked up, uh, the 1 patient that required surgery. So again to echo what Doctor Van Alman said, FAST may be very helpful in the hemodynamically unstable patient where you're trying to identify hemoperitoneum. You're not sure what cavity. Uh, is contributing to your, uh, your issues, and then the final, uh, one on fast. This is looking at fast and CT variability by the 14 centers starting from left to right. Uh, this is MUSC. We're center one. We we fasted everyone and we scanned about 21% as you go down and fast, there was not a direct correlation in CT. We're kind of all over the place on, uh, how many CTs we get. Interestingly, of the 14 centers, only 1 used a negative fast to reduce CT, and 2 centers actually scanned, did more CTs after fasting patients. So, uh, we're not using F effectively to determine which patients can successfully avoid a CT. So don't, don't use fast to give you a false sense of reassurance that you, you don't need to scan. Uh, the patient, and that's kind of the scatter plot. I think that's a, that's a reflection of who's doing the fast that that generally, generally speaking, it's being done in the emergency room by ED physicians and sometimes by the surgery residents or fellows, and yet they're not, they haven't gone through a 3 year fellowship in radiology, uh, or residency in radiology, so they are not as good as an ultrasonographer might be who's in the. Who's in the trauma bay and so it'd really be interesting to see if you had a real well trained ultrasonographer down there doing the fast if the results would be any different. Yeah, I agree this is more a criticism of how we do fast than the technique itself. I will say, um, what we learned in this study is that, um, every single patient that had an intervention, whether it was a transfusion and the few that had an angio or an operation had a CT scan first. So fast really didn't change our management. Um, these patients are mostly hemodynamically stable. Scans are really quick to obtain, and they often impact your, uh, clinical practice. David, uh, I, I, first of all, Sophia Abdulhai, uh, the, the research fellow here in Akron, I'm going to task you, Sophia, after this course to send out all the participants what we feel were the key. The main take home point from what each of you are talking about, that's the key. And if you could, and also Sofia, if we can post in the chat these articles that they're referencing, the articles that they published so everyone can have these, these links to the articles, Chris. Give me the bullet point key take home points that we now need to know that's that's new and different. Yeah, the, the main take home point is to review the clinical prediction model. 97% of the patients that present following blunt trauma are hemodynamically stable. These are patients that you have an opportunity to do a a solid physical exam and history, get screening labs. Uh, in this case we recommend an AST and, uh, a lipase or amylase, get a plain film of the chest. And to identify a patient population that likely does not need an abdominal CT, this is what we would suggest as the best practice to avoid unnecessary abdominal CT. I think it also provides guidance to the 90% of providers out there that don't see children all the time. They're evaluating the the kids in their ED that they don't need to scan every patient before they call us about the patient. There are a lot of other injuries the patients have that they may benefit from pediatric evaluation. We're happy to see these patients and transfer, and we can decide who needs a CT. There's certainly time. Uh, you don't have to rush everybody to the scanner. OK, that was great. Hold on, David, one second, and then I want to ask David Norica 4 bullet points from what we've learned from Atomic. 4 points, um, or 3. Number 1, failure is, uh, can't be, can't be guided by the, by an algorithm. You basically, you, um. You, you fail when the surgeon says you fail. 40 per kilo is a good cutoff for failure. Um, shock index is great for, for letting you know who's not in shock. It may not be great for telling you who needs an intervention, but it will, but if your, if your shock index is not elevated, you're, you're, you can relax pretty significantly. Um, last take home point is, uh, I'll, I'll refer back to Streck, which is his prediction rule is only 5. Picar was 7. Um, his prediction rule is independent of GCS, and I think that, uh, that the pecan basically was only useful in kids who, who had, uh, 14 or 1514 or 15. I think that, um, that, that really that, that, uh, that, that that is a great contribution to the literature. So I'll, I'll hand it to Chris for that. This has been fantastic. David, did you have a last 22 quick points. So one question I have is that we have a group that's the intraabdominal injury identified. There's the intraabdominal injury that requires intervention. I think there's a third group that's abdominal injury that we just don't care about. We've seen over my generation, we've, you know, gone from prolonged hospitalization, multiple labs for a grade 2 liver lack, and we know that those kids probably could walk out of the hospital and without any, probably without any. So my question is one, can we, first question is, can we, um, find a third category where we don't really care? The second question, I care, but. We care about the kids. Yes, yeah, we just don't care about the injury, right? And the second question is we are, we're all fortunate to be at kind of high-end institutions and we're talking at, you know, whether it's Pecarn, whether it's Peds SRC, Midwest Collaborative, PS, but, you know, a tremendous amount of care is done at the community hospitals, and we have to think about whether it's telemedicine, education, outreach to say help them. Uh, they don't have safety nets. They don't have rescue strategies for patients who fail to make sure that these are applicable and can be generalizable. What do you think about the the question, are there solid organ injuries that we really don't care about? All right, so that is that that um. There is a subset of solid organ injuries that we probably don't need to know about. When we find a grade 1 or a grade 2 injury, it's very, very unlikely that, that, that they're going to fail non-operative management for that injury. Now they may, they may fail non-operative management for a bowel injury or pancreatic injury, which is what we saw. And if you look at all the kids that fail, the, the, the failure rate of non-operative management of solid organ injuries is 7%. And everybody said, oh, it's 3% is, well, no, actually it's if you define failure as a laparotomy, it's 7%. 3.5% of those patients are failing because of bowel injury or pancreas injury. 3.5% are are are failing from bleeding. The other thing is, um, if you have an isolated spleen, you are incredibly unlikely to fail. If you have an isolated liver injury, you're unlikely to fail. It's when you start getting patients who have both injuries that, that really your, your risk of failing goes up tremendously. And so, um, yes, there is a segment of, of injuries that we don't need to know about. We, we just haven't quite figured out what to do with, with that at this point. All right, we're, we're running way over in time, but Aaron Lipscar has a question or a comment. One quick guy I guess. Question or comment just about the scan because we've we've talked a little bit about it and from the uh senior mentors of pediatric surgery heard a lot about hating and uh and and and such and we suffer in my institution of the same problem of low level residents scans on on every patient and pushing them out of the way so we could actually evaluate their trauma. But my problem with it is the FAST scan is another point of care ultrasound technique that we as surgeons, I think should take, we should do it, right? So instead of the low level resident, if your fellow or your 4th year general surgery resident or you or I learned how to take a probe and quickly put it and find out the information, then we, we, you would trust that you're not gonna trust the, the intern in the ED who's learning on your patient and not and doing a fast very slowly. But it might be a very useful thing, and I, I always imagine the days that we as surgeons or doctors have ultrasound probes that connect to our phones and look for appendixes and take them out in trauma and gather the information that we as surgeons can help the our assessment. Now, I, I, let me just address, I think you're absolutely right. The, um, you know, um, you know, uh, you know, Witt has, has one set up at his institution. We have kind of a little different one at ours and. You, you have to, you know, you have to do 50 ultrasounds to be, to be qualified to, to do a fast in my institution, and it's not that hard if you're, if you're, if you're fasting patients who are hemodynamically stable. Um, I think it's important that the surgeon do it. I think that, that the, that the reason that we should keep doing the fast ultrasound, um, partly is so that you're good for the unstable patient like you guys discussed, but I think that when you, when, when contrast. Um, IV contrast for ultrasound becomes commonplace. Um, we're gonna replace CT with ultrasound. I don't wanna, I don't wanna spoil it from, you know, from the next talk. I'm, I'm hoping that that's what's coming next, um, but, uh, but I think that I that IV contrast for ultrasound is gonna be revolutionary. Actually that's my cue. Oh, that was a great segue. Perfect.