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Behind The Knife: The Surgery Podcast
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Duration: 01:05:45
Dr. Matthew Martin is a leading trauma surgeon who has served multiple deployments in both Iraq and Afghanistan. In this week's episode, he reflects back on his deployments over the past 10 years.
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In this week's episode of Beyond the Knife, Dr. Matthew Martin, a leading trauma surgeon who has served multiple deployments in Iraq and Afghanistan, reflects back on his deployments over the past 10 years and what medical advances we have seen move from the war zone to the civilian sector. He focuses on prehospital care and initial treatment strategies in, for example, rural or war zones.
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Peter. You know, we talked to Dr Maddox. We talked to Ben Starnes and we talked a whole come on the behind the night podcast previously. And it's funny, the little bit slightly different thoughts on angles about the Rebel A system. You know how how practical, how it should be implemented. Is it gonna hit and again not only in the combat setting, but also in civilian trauma? I'm curious as to your thoughts about that. And where is it now? And where do you see it fitting if it all, as we go forward into into use in the civilian sector, Yeah, and and that's I think that's the usual sequence of names that people think of in trauma. Usually think Maddox, Holcomb, Martin s so it zumba Wing to be mentioned in the same breath as those kind of names. So from my lower level opinion, I think robo is another interesting technology and and that's that's really because our our final hurdle is trunk or hemorrhage. We do not have an answer for trunk or hemorrhage other than get into a surgeon as quick as possible and do damage control resuscitation and hypertensive resuscitation of that we don't have an answer for those patients. Uh, Rabbo A is one potential answer. There's very good animal data supporting it. It works, you know, essentially cross clamp the aorta and with a lot less physiologic insult than doing an open cross clamp. I think the big hurdle in that is there's a lot of push and it's being sold as this is a pre hospital intervention and we are nowhere close to being able to deploy. That is a pre hospital intervention, because one you need to look at efficacy, especially for pre hospital interventions. But the other thing you have to look at is the price you pay. If you're wrong on the complications, that can happen. And and there's such potential complications of of applying this technology wrong on. If you just think about a lot of a lot of active surgeons and trauma surgeons, you tell him, Go put a balloon in in the aorta and they wouldn't be comfortable with it. And now we're gonna tell a medic to do that in a battlefield environment. So I think robo is great. I see it as an e r intervention. For now, I don't see it moving to the pre hospital environment anytime soon. Other than very select situations like like a situation where a surgeon or a ER physician is in a frontline area, or for very verily select highly trained medics, and in our community that would generally be the Special Forces medics. Outside of that, I really don't see it as a pre hospital.
at Madigan Army Medical Center. He's going to talk to us about initial evaluation and resuscitation of patients both in the civilian sector and in trauma. In our random fact of the day, we're gonna talk about mid foot injuries and the famous EP in M that has gone on with that. And finally, our tips and tricks. Dr. Matthew Martin is gonna tell us a little bit more about penetrating chest injuries. All right, all that and more coming up. But first, our opening shot. Okay, so in today's opening shot, we're gonna parlay a little bit what we're gonna talk about, Dr Martin in terms of combat trauma and initial resuscitation and some of the more practical points in terms of getting patients in that pre hospital setting. So it's important. Understand? When you talk about organizational structures, there's really three different components of it. Number one, the pre hospital component in this, uh, this involves who's taking care of the patients. How are they getting their what abilities do they have in that particular one, which is obviously different in a rural setting versus A versus um, or city setting? And then, uh, in the emergency department and then finally getting the patient to the operating room. Jake Trump is really different than medicine. How do we think about these? It's it's obvious, but it's well, we're saying, Yeah, you know, and these, you know, generalizations. But in general, you know, medicine is is slow and oftentimes not urgent. Where trauma your rapid. We're talking seconds. Two minutes for life. Um, you know, medicine. You have time to go through Thorough. Consider all the data, make the diagnosis and treatment trauma. You gotta prioritize. Your gotta allocate. Your resource is prioritize the patients. Often you're working with incomplete data and you have to initiate therapy before you really have all the information. Yeah, I think that's one of the major components is we're talking about. Oftentimes you're initiating therapy prior to making an understanding. What? The diagnosis. You're making the diagnosis as it comes in. So question to you. You've got a 20 year old guy in a pre hospital setting in. He's a soldier. You're in a combat environment. He's got a gunshot wound to the abdomen. He's unconscious. Heart rates 100 twenties. What? Pre hospital? Uh, intervention should be done. You know, we talk about our ABC s A T l s. And you know, when you go through the thing, where are you at? What are you gonna do? Do we have the ability to have a you know, Do we have good trunk, all hemorrhage control? And that's something that we're going to talk a little bit with Dr Martin about. And should that patient undergo, uh, in innovation. So innovations been looked at in a couple of different settings. Can you talk a little bit about life saving innovation, if you will? I'm sure. You know, a couple different people have looked at this. You know, there's some data coming out of the Los Angeles County with Murray in the journal trauma 2000 That showed a worse outcomes, actually, in patients with pre hospital intubation, particularly for Children with head injuries. Um, and you know, other studies in general, Trauma 2000 to the German German trauma system showed prolonged scene time, increased fluid requirements and no survival. Bennett thio intubation in the field. Yeah, it's really it Z. It's really interesting when you think about this. Obviously, we're not saying that that if a person needs an emergent airway that you shouldn't try to get that emergent airway access. But when you really look at some of the data out there, it questions, What are we doing at the scene of the at the injury of the accident, and could we do it?
at Madigan Army Medical Center. He's going to talk to us about initial evaluation and resuscitation of patients both in the civilian sector and in trauma. In our random fact of the day, we're gonna talk about mid foot injuries and the famous EP in M that has gone on with that. And finally, our tips and tricks. Dr. Matthew Martin is gonna tell us a little bit more about penetrating chest injuries. All right, all that and more coming up. But first, our opening shot. Okay, so in today's opening shot, we're gonna parlay a little bit what we're gonna talk about, Dr Martin in terms of combat trauma and initial resuscitation and some of the more practical points in terms of getting patients in that pre hospital setting. So it's important. Understand? When you talk about organizational structures, there's really three different components of it. Number one, the pre hospital component in this, uh, this involves who's taking care of the patients. How are they getting their what abilities do they have in that particular one, which is obviously different in a rural setting versus A versus um, or city setting? And then, uh, in the emergency department and then finally getting the patient to the operating room. Jake Trump is really different than medicine. How do we think about these? It's it's obvious, but it's well, we're saying, Yeah, you know, and these, you know, generalizations. But in general, you know, medicine is is slow and oftentimes not urgent. Where trauma your rapid. We're talking seconds. Two minutes for life. Um, you know, medicine. You have time to go through Thorough. Consider all the data, make the diagnosis and treatment trauma. You gotta prioritize. Your gotta allocate. Your resource is prioritize the patients. Often you're working with incomplete data and you have to initiate therapy before you really have all the information. Yeah, I think that's one of the major components is we're talking about. Oftentimes you're initiating therapy prior to making an understanding. What? The diagnosis. You're making the diagnosis as it comes in. So question to you. You've got a 20 year old guy in a pre hospital setting in. He's a soldier. You're in a combat environment. He's got a gunshot wound to the abdomen. He's unconscious. Heart rates 100 twenties. What? Pre hospital? Uh, intervention should be done. You know, we talk about our ABC s A T l s. And you know, when you go through the thing, where are you at? What are you gonna do? Do we have the ability to have a you know, Do we have good trunk, all hemorrhage control? And that's something that we're going to talk a little bit with Dr Martin about. And should that patient undergo, uh, in innovation. So innovations been looked at in a couple of different settings. Can you talk a little bit about life saving innovation, if you will? I'm sure. You know, a couple different people have looked at this. You know, there's some data coming out of the Los Angeles County with Murray in the journal trauma 2000 That showed a worse outcomes, actually, in patients with pre hospital intubation, particularly for Children with head injuries. Um, and you know, other studies in general, Trauma 2000 to the German German trauma system showed prolonged scene time, increased fluid requirements and no survival. Bennett thio intubation in the field. Yeah, it's really it Z. It's really interesting when you think about this. Obviously, we're not saying that that if a person needs an emergent airway that you shouldn't try to get that emergent airway access. But when you really look at some of the data out there, it questions, What are we doing at the scene of the at the injury of the accident, and could we do it?
and died in 18 47. He's a French surgeon and gynecologist who described this injury during the War of the Six coalition. You didn't take French and, uh, did not more Spanish. That's obvious. Uh, during the Napoleonic Wars, Jock encountered a soldier who suffered from vascular compromise in secondary gangrene on the after a fall from a horse. What? How did that happen? You got his foot caught in the stirrup, and the horse came out from under him. Subsequently, Lisfranc performed an amputation at the level of the Tarso metatarsal joints in that area has since been known as the Lisfranc Joint. Is that all he did, though? Uh, no, actually, Jacques Lisfranc, Day seven. Martine is actually, surprisingly, not an orthopedist. He is a pioneering French surgeon and a gynecologist. He invented a number of operations, including removal of the rectum, the with autonomy and women and amputation of the cervix. And that has been your random fact to the way so welcome to behind the knife. We are absolutely thrilled. Toe have Dr Matthew Jeffrey Martin, who is the trauma medical director and director of surgical research at Madigan Army Medical Center. He's also the chair of the Army Committee on Trauma. Matt, welcome to behind the knife. Thank you. It's great to be here at the B t K corporate headquarters. Awesome. So, Matt, for those who don't have a much of a understanding about your background, could you walk us a little bit through where you're from, where you trained and how came the point where you're at your surgeon your career? Sure. So I'm from and grew up in New Jersey, Jersey. Represent? I went to Undergrad Grad school in med school at Boston University. So spent quite a bit of time on the East Coast. Uh, course I was on Army scholarship of medical school. So then it came out West Madigan Army Medical Center, where I did my residency. I did my fellowship in trauma Critical care at USC Los Angeles County Hospital on then. Since then, I've been back at Madigan. His staff, except for several nice trips to the Mideast. How did you get what made you decide? Thio, the army medicine around? I was actually Army ROTC in college and and I had one big driving factor for that money. Yeah, Boston University was pretty expensive. I needed some way to help pay for that. Three Army seemed like a reasonable option. Also, I have several family members, including my father, who were in the Army. So So you know, that played a part s So I was ROTC, uh, did my time in college served after college on. Then when I got accepted to medical school, it just it seemed like a natural fit on. I wanted to continue on with a military career continues to be lucrative, I'm sure. Oh, yeah. OK, now it's time for the segment of podcast we called the dissection of the day. And this is the segment where we delve more in depth about a particular surgical topic. And since you we have you with us today, Dr Martin, we thought we would way would, um, talk about lessons learned from the combat experience and how we can apply that to civilian trauma. So let's start with the pre hospital resuscitation. Um, I wonder if you could talk a little bit about some of the human static agents and devices that have come out of our our combat experience and and how we can transition those into civilian practice? Sure, So and I think pre hospital is probably where we've made some of the most important advances, at least on the battlefield. And that's starting to be translated to the civilian sector. Uh, and we and we've really proven the benefit of some incredibly high tech products, like a tourniquet, a stick and a piece of Velcro. That's probably been one of the biggest advances in the combat experience. And it wasn't just let's get a tourniquet that works. It was, Let's feel tourniquets. Let's have every soldier with at least one better off to tourniquet. It's in their uniforms on and probably experience from the Ranger regiment that Russ Scott Wall has published of. They trained every soldier you know to be a combat medic to apply a tourniquet to apply human static dressing, and they showed a marked decrease in there. They're killed in action, no preventable deaths, which, if you look at the big Siris, are preventable. Death rate is about 25% battlefield deaths. Eso tourniquets. The simplest thing in the world has been, you know, responsible for probably more lives save than anything else on, then the the other. The other big advance has been humus, static dressings. You know, for hundreds of years we've gone to war with nothing mawr advanced in a gauze dressing. This is the first wars we've gone with something more advanced than that on. We've gone through a bunch of generations of products, and we have some very good, uh, products now that could be applied to wounds that that aren't necessarily something you put a tourniquet on. There's some that you feel are better than others. Well, to do the party line The Army party line, which is the Tactical Committee for Combat Casualty Care. Uh, they approved dressing has been combat gauze for the past about five years. They just approved two of the kite is and gauze products as as effective as combat gauze on DSO, though, and those ones I have the experience with, uh, those air called passive dressings. They're very good at stopping bleeding. They don't bring any external clotting factors to the game. I think the next big advance that we're looking at now, our so called active dressings and those actually contain, uh, precursors or active coagulation factors on so theoretically they should work in the cold coagulate Catholic patient where some of the current status dressings might fail. And there's a whole bunch of other, you know, gee whiz technologies and devices that air coming on the market. Are any of those active dressing down the market currently with the clotting factors? Several of them are there. There there really only approved for mostly inter operative use, Andi, and really, the main ones are ones that have fibrinogen or fiber and precursors on there. There's a couple of them that are approved mainly for use in the are one of the problems in in terms of trauma use for those is there generally very small. You know, they're they're a couple centimeters square that you can put on a little, you know, bleeding liver or spleen Counselor tear eso. The next generation will be advancing those to a bigger product that could be applied to a large trauma wound that's bleeding or even interrupt to a big, solid organization. It's bleeding continued on the controlling hemorrhage topic. We know that with the Zaidi blasting things we've seen, we've seen a lot of junction all hemorrhage, and they could be pretty devastating. What have we come up with that have we hadn't made any advances in that field. Well, the human static dressings that I just mentioned. Those were really developed for junction hemorrhage. You know, you have three categories Extremities Junction aligned, then trunk all extremity tourniquet. It's are the main solution. If they still bleeding at a second tourniquet, you can add him a static dressing. But those were really developed for the junction all hemorrhage, Uh, and the drive behind that. A lot of that was the Somalia experience. You know that many people have seen a Black Hawk down the one scene where the soldier has ah high formal vessel that retracts and bleeds to death on the some of the doctors like John Holcomb, who came out of that. And Peter Rhee, who had other experiences with those types of wounds, said, We need a product that control that type of wound, and that's where they came out with the human static dressing. So, Andi, that's why I think combat gauze and the other. Gough's role products are probably the best because you know their new advanced dressings. But they're basically a Gough's role for the medic. They know how to pack gauze into a wound so they don't get a lot of extra training. The other big excitement now is they've developed junction alternatives that could be applied to these junction. All injuries, mostly ephemeral. One of them can be applied to Axler your subclavian. There's three or four products on the market. There's Ah, one called the Crock one called the Jet. There's a Sam, the same coming that makes the pelvic binders, uh, the jet in the sam appear to be pretty effective. Those were being fielded. Now on we have at least 15 or 20 documented uses of them in three.
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