Latest / Behind The Knife: The Surgery Podcast / BIG T Trauma Ep. 27: Is Vascular Trauma Care a Lost Art?
Transcript
- BIG T Vascular Trauma Training === [00:00:00] Hello, this is Patrick George off with Behind the Knife. I got a scenario for you. It's 1:00 AM Saturday morning and a trauma arrives with A GSW to the proximal thigh, and they have no distal pulses on that leg. Who's doing the repair? Is it trauma or is it vascular? What if it's below the knee? What if it's the upper, upper arm, the subclavian, or even the IBC? There are countless factors that play into the scenario. And this includes trauma surgeon, skill and experience. Whether or not AO surgeon's available, how stable is a patient, how complex is the injury? Is there any potential benefit from an availability of endovascular treatment? What are the institutional politics? There's so much that goes into this. So acknowledging that every patient, each institution, and any given night on call is unique. There is concern among the surgical community that the bulk of the responsibility for addressing. Traumatic vascular injury has shifted towards the vascular surgeon. So why is this and should we, in the trauma surgery, community care? [00:01:00] Certainly we care. So we can dive in and talk about this a little more. So to help us get through this. Uh, we've got the Big T Trauma co-host, Dr. Teddy Puzio, who is a trauma surgeon at University of Texas in Houston. We've got a new guest, Dr. Brian Gilmore. He's a vascular surgeon at Duke and associate PD of our integrated vascular surgery residency. And another new guest, Dr. Joe Debose, who is professor of surgery at the University of Texas in Austin, where he's director of the Integrated Trauma Research group and director of Vascular Resuscitation and trauma management. Joe has particularly unique insight into this topic because he is dual trained in both trauma and vascular surgery, \ Dr. Dubbo is also retired colonel in the US Air Force. He retired in 2021 after 20 years of active duty. Joe, thank you for your service. Let's get right back into this issue. So again, we have this GSW to the proximal thigh, no distal pulses. It's 1:00 AM Saturday morning. Let's go down the board here. Ty, Sergeant, UT Houston. Who takes this patient [00:02:00] to the, or trauma. Okay. Joe, university of Texas. In Austin. I'm a little convoluted. We have two dual trained people here who take trauma calls, so it may be a vascular surgeon who does it, but I'm on my in trauma duties and, and I think that's the person who's at bedside when the patient arrives it, it's inherent if you're gonna move emergently that the trauma surgeons there, the vascular surgeon has to come from home. Great. Brian? Like Joe said, uh, it does get a little bit complicated and convoluted. So I'd say it depends, um, on the, uh, presence of other injuries and how stable or unstable a patient might be. Yeah, it all depends, right? I think there's something that's really interesting that a lot of, surgeons may not know both on the vascular and the trauma side that the American College of Surgeons does not require. That level one or two trauma centers have a board certified or board eligible for that matter, vascular surgeon available. Instead, they state that the most the trauma centers must quote, have continuous availability of vascular expertise. So contrast that with [00:03:00] orthopedic and neurosurgery where level one and two trauma centers are required to have board certified liaisons. Dr. Debo, that raises the question of who determines. Vascular expertise. And what are these, these standards then that trauma centers, need to uphold. Yeah, it, it's a, it's a great question because the expertise is defined by the training, right? And so the, and the training has changed and continues to evolve over time on both the trauma and the vascular side. I really hope the American College of Surgeons Committee on Trauma changes that, and I think just by naming a, the presence of a vascular liaison, that doesn't mean someone who. Does all the vascular injuries, but what it does do is it creates a pathway, much like ortho and neurosurgery, where you have some tail end ownership, uh, of these patients. No matter if Teddy takes somebody back and whether he puts a stent or a GRA or a graft in the patient that's gonna need to be followed for years, it's gotta have a natural history that needs to be established. [00:04:00] And trauma surgery is unlikely to do that at your institution. So I think having the liaison in the mix for nothing else than to take ownership of the long-term followup with these patients and provide some additional expertise really is what's needed to move forward. But yet every, I have been at several institutions in my military career, moved around quite a bit. And the relationship here is very institution dependent. Uh, a lot of personality and it various institution drives it. A lot of tradition, which in my mind equates to very thick walled silos sometimes, uh, can dictate some of these things. And I think that, uh, to make generalizations is very challenging. It is truly an institution dependent skillset and approach to these injuries. Yeah. And this is a, a good segue. You mentioned, vascular training 'cause that's what determines people's expertise is their training. And you can look at a number of different studies that show this, but, [00:05:00] one study looked at 2012 to 2022, so a 10 year period of A-C-G-M-E case logs. And this study found that general surgery residents perform an average of 2.4 vascular trauma cases over their five years of training, just 2.4 cases on average. Now, certainly it's different. Depending on what kind of institution you're in. But this is compared to vascular surgery residents who perform 25 vascular trauma cases over five years, and vascular surgery fellows who on average performed 22 cases over two years only. Furthermore, the Acute care surgery fellows who participate in the double A ST approved programs have relatively low vascular case requirements. And it's important to note that these are not all trauma cases too. These can be elective cases, for example, double A ST suggests three iliac artery exposures, two popliteal exposures, et cetera, over the course of the fellowship. With that we'll start, Joe with you again, then move down the line. Does this exclude the current or even the next generation of trauma surgeons from being [00:06:00] able to fill that a CS requirement that we have, continuous availability of expertise yeah there's a lot of variables at play here, right? There's the increase in growth of specialization, uh, even within any given vascular group, and Brian could probably test this. You've got an aortic person, a vein person, probably got somebody who specializes in carotid stenting. So even the, within the field, uh. The expertise continues to refine and hone down to smaller and smaller little subsets. I think the way forward probably is we need to do something about training. I don't have the box on that. I think there are some opportunities to promote pathways where people can, in the same institution, even perhaps pursue trauma and vascular training. So that when they come out the tail end of that, they can be the champions at major institutions for vascular injury. And I think we gotta think about the injury itself differently. We talked a little bit before we started taping about the PERT team corollary here, for those not familiar pulmonary [00:07:00] embolism response teams have cropped up at a lot of major centers because this is a life threatening entity that needs some. Diagnosis and management from a gateway keeper on the front end. Optimization identification, you need some technical expertise to provide around the, the clot removal that is in heavy into endovascular, and then there's a tail end critical care piece. And I think that the correlate here for vascular injury is apparent to me, right? You've got the trauma surgeon is the gatekeeper, and you've got whoever needs to move into the technical phase. In, in the pert world, it's cardiology, ir and vascular oftentimes interchangeably sharing that call, and then on the tail end, they return to the pulmonologist. And the medical critical care team for Perc for their continued care. And I think that the corollary here would be that they would move back into the surgical ICU or the, the trauma ICU, uh, to care for all their other injuries in the context of their vascular injury. So I think there's some better ways to think about these things moving forward, and I hope we can work [00:08:00] together to embrace some of those opportunities. Yeah, I agree with Joe and, and we've talked about this before. Ultimately trauma as a team sport, right? I mean, I think that the difference is the level of involvement. Of each separate entity, right? Like trauma surgeons can't manage every single vascular problem. But the degree of which depends on the volume at your center and the volume of your training. At our center the trauma surgeons do a very large majority of the vascular trauma independently. But there are times when, we still need help. And some centers that don't do as much vascular trauma, there's not as many reps for the the trauma surgeons. There's probably more involvement with the vascular surgeons there, but the ideal environment is, it's not like trauma surgeons just tap out every time a vascular trauma patient comes through the door. Right? I think that's totally the wrong way to do this. We shouldn't just. Hand over the reins to the vascular [00:09:00] surgeons. But I mean, there's something to be said about working as a team, right? Even patients that Vascular's gonna do a large majority of the case trauma surgeons should be able to get started and do the approach and, you know, whatever it, it takes to kind of work to together, I think it just looks differently depending on where you are in your center. Yeah. And Brian, we have a good working relationship at Duke. What, how do you see it there? So I agree with everything that's been said so far about how this really is a multidisciplinary process, right? People are frequently. Not limited to just one injury and in the poly traumatic patient, I think that the trauma surgeons probably do a better job of kind of seeing the whole field with respect to a patient's overall status. I think the comparison to the PE response teams, that Joe made earlier is,, is a good one and that there are different components of a patient's care, some of which are. Technical, some of which are limited to, uh, a specific injury, but [00:10:00] others are much more encompassing of, again, that overall picture. And I think that it's important that both teams communicate clearly and work well together and, uh, develop and maintain a good working relationship. Yeah. We have to acknowledge that that's part of trauma surgery training. The fellowship and critical care aspects of it you have to take care of the whole patient. That's a whole idea, right? It's the sick. Surgical patient. The quarterback still remained the trauma surgeon. Joe, do you have any thoughts on this we hear this and you've heard at a conferences and , it's like, well, you know, it really needs to be the trauma surgeon who's doing maybe even everything people might argue How do you, address, that argument, and even the other side of it when it comes to vascular surgeons being involved in so much vascular trauma and recognizing what that means when you're dealing with a, critically unstable patient. Yeah. It's a, challenging question. I think that the practical reality is there will always, for the foreseeable future gonna be an open [00:11:00] element to these injuries, right? And these injuries are often, I think about them often as a uh, a story told in many chapters. Identification, diagnosis, right? Initial management, often entailing, sometimes damage control because these patients do have a lot going on. So shunt placement vessel exposure should be in everybody's wheelhouse, and I think there are a lot of vascular trainees perhaps that are not as comfortable with that, and they need to be, get as comfortable with that. They need time on the trauma service and, and exposure these injuries to manifest those skill sets as well. But the exposure and control. For the open cases and then the, the stable blunt cases, which is where endovascular has really made its thing. And and I think in some injuries, clearly blunt thoracic aortic injuries, an example where it's changed the way we do business for the better. And one could argue some of these junctional injuries are very similar. Axis subclavian, iliacs, uh, really those injuries are optimally managed even long term probably with. Endovascular technology. So how do we [00:12:00] marry in these skill sets? Are there some of those skill sets that can be leveraged by the trauma surgeon who's there initially while the vascular surgeon is coming in? So. The exposure and the shunt placement that should be squarely in every trauma surgeon's skillset. And then they the vascular surgeon can arrive and you can figure out what you want to do. I, I would hope together, everything's always done more expeditiously. When you do these things together. You learn, your trainees learn, they observe. And even in the endovascular world trauma surgeons getting good femoral access, good, solid, reliable femoral diagnostic access, maybe shooting an angiogram. Putting a balloon in the right place. Uh, you know, Rebo A has been beat through the, the mill on, on the, in the trauma world, but it's not the only place you can put a balloon to get proximal control and it can buy time for your vascular counterparts to, to leverage, uh, all the toys that they can bring to bear. And it's important for the trauma surgeons to be in the room and know what the limitations and the opportunities for those toys, those technologies that the vascular surgeon has. So it's, it, it has [00:13:00] to be a team sport across the board. Yeah. Teddy, when it comes to training, do we need mandates from A-C-G-M-E or A A ST? Especially when it comes to training general surgeons. We have asset, right? Adam, even the best course, these are all, excellent opportunities, but they're, not always available. They're, expensive. It's very expensive to run these courses. Logistically intensive. It's usually a one time. Deal. I'd be remiss if we did not, , plug our very own trauma surgery video atlas, which is not a one-time deal. Always available. A handy dandy on your iOS,, or Android app. Middle of the night someone comes in, you need to expose the femoral artery or, or get to the IVC. Quickly, we got you covered. But yeah. Teddy, going back to this question on, education. If you had it your way, what would you do? That's definitely a, a debatable topic. Do we need mandated benchmarks? Yeah. I think you have to, we live in a world where you have to have paper showing that, but I, I worry that even with these benchmarks, like, we've all, [00:14:00] we all remember what it felt like logging cases, right? Like even if you're the second year resident. Just riding the Bovie, putting it where you're told you're gonna log that case. Right. So I do worry that in some training institutions, you're the a CS fellow who's doing a vascular rotation and you're just the guest on the service, right? You're not doing that case. So, I am fortunate to have trained in a high volume center where, you see what it feels like to get. Control of a, a vascular injury. It's totally different than like an elective fem pop. So, I mean, to answer your question in a long-winded answer, yeah, there has to be benchmarks, but I don't, I don't know that benchmarks alone are a great marker for competency. I mean, as far as the courses that you mentioned, yeah, definitely. I mean, I, yes, they're expensive, but I am a very big. Proponent of asset, specifically Adam, you know, we do those here, even in a high [00:15:00] volume center. We do those here because I think it's a good way to. To train residents preemptively, so they kind of know what they're up against when they're in the or. And those aren't just valuable for the trainees. It's available for the trainers too. Regular reps, teaching those courses and getting your hands on, vascular anatomy and cadavers and exposures and a real bleeding heart. Is extraordinarily important. Now you mentioned logging cases but even then we just talked about the studies that showed that people aren't even logging those same number of cases. Right? The case numbers have dropped drastically and Brian, your associate program director for integrated vascular residency, of which, many large academic centers, even smaller ones now have integrated vascular residencies and that is a direct, head-to-head. A competition when it comes to the availability of vascular cases. We also, we haven't even talked about endovascular yet. Depending on what you look at, there is a massive 200, 300% increase in endovascular cases being performed by vascular surgeons from the early two thousands [00:16:00] into, now essentially. So. There's a big competition there, Brian, when it comes to education. Who gets those cases? Can we get the general surgeons in there to get those cases? Or do the vascular surgeons really need that open exposure for a big open aorta or a, or a fem pop because they're doing so many grams and stents. Yeah. So I think that's a really interesting point that you raised, and one that's not necessarily given to an easy or straightforward answer like Teddy touched upon the devil is in the detail with any sort of case minimums, right? What is the threshold? What is enough? Um, what is it that gives someone or can reasonably be expected to give someone competence to do something independently The, biggest area in which this has been of interest in the vascular surgery literature specifically has been with respect to open aortic surgery. If you go back 10 or 15 years, there were very real concerns that open aortic surgery was functionally going to be a lost art, and that trainees were going to graduate doing single digit, open aortic, uh, surgeries from [00:17:00] vascular surgery. Training programs, increasing data in recent years has suggested that the situation isn't nearly so dire that the, uh, number of open aortic surgeries that are being done by graduates is not what it was in the 1990s, and frankly, it probably never will be. But that, uh, people are having enough of an exposure to be safe and confident and competent with that skillset. The. Corollary issue is with, uh, how do you balance multiple learners and what is it that people need to expect or can reasonably be expected, uh, to know at any given level of training and in any given paradigm? I think to Joe and Teddy's PowerPoints that vascular exposure and control. Are completely reasonable expectations for trainees. There's a lot of nuance in some of the decision making around reconstruction. But the ability to expose a vessel safely and to stop exsanguinating hemorrhage is, I think a, a reasonable expectation for a skillset. So how do you go about getting, uh. [00:18:00] Trainees of every program and at every level the case volume that they're needed, to, uh, achieve that goal. That's a really complicated question and frankly, the subject of a lot of ongoing research. Yeah. And it, uh, requires a good relations and a back and forth, so the trainees get what they need. So, Joe, you acknowledged earlier, there's certain injuries like blunt thoracic aortic injury. The endovascular approach is far superior. But, uh, with that said, are you worried that vascular surgeons are less prepared for open vascular trauma cases? I, I, I think they're as prepared as they can be, and I think the vascular community is doing a, a good job to be thoughtful about that as much as you can. The practical reality of endovascular technologies is they're gonna take over some of these things. They make them, it's better for the patient. From where I sit, there's ample opportunity still to maintain those with vascular, uh, surgeons from an open standpoint. And, um, we just need to figure out ways. From an organizational standpoint, from a training standpoint, to get the acute care surgeons in the more in the room, [00:19:00] uh, at the training level so that they can understand the exposures, how to be good assistance, how to get it started themselves, and all the pitfalls that can occur which I think is gonna be paramount to success. EPAs, right? This could be a plug for that. You logged the case, but what'd you really do? How much autonomy were you, granted on that case? How difficult was the case? Having some mechanism, uh, an EPAs being the chosen mechanism going forward for assessing. The level of execution on any given case vascular, particularly for this over a period of time. I think it's gonna be very helpful. When you talk about graduating residents and what their skill sets, are, that's something that's a, objective and will hopefully at some point, if this is done correctly and followed through be measurable to some degree. And so going back to saying, well, how do we know that the. Trauma center has the vascular expertise that's needed. In a perfect world, that might be [00:20:00] something that contributes to knowing who has that expertise. Brian, any thoughts? You're an EPA guy. So I think that EPAs have potentially. Uniquely nice fit with respect to endovascular, uh, work with general surgery trainees. And what I mean by that is that the difficulty of endovascular surgery is not just, getting the needle into the blood vessel at the appropriate position and threading a wire and selecting things. Uh, it goes into the the knowing what the next step is gonna be, knowing what the equipment is. So the way I describe it to my trainees is that, you know, they may have learned surgery, but now they're learning surgery in another language. And understanding that language and the ability to think laterally and conduct even the basic steps of an endovascular procedure does not necessarily have a lot of one-to-one translation from open surgical techniques. And I think that EPAs are a potentially useful way for us to break that down and break down an endovascular procedure into its. [00:21:00] Constituent parts, uh, and to teach those parts so that way a training is able to understand and proceed through the full components of an endovascular procedure. Joe, there was an interesting survey that, uh, was done between some trauma organizations and vascular societies, and they wanted to figure out, what did vascular and trauma surgeons think about vascular? Trauma and taking call and covering, and this is done in 2021. And they found that vascular surgeons had greater experience and comfort managing vascular trauma compared head-to-head to their, trauma colleagues. The survey also found that there were more trauma surgeons who felt that they should manage vascular trauma than the vascular surgeons, and that more trauma surgeons would like to incorporate additional vascular trauma into their practice than vascular surgeons. So the, trauma surgeons, they want it, right? They want to do more vascular. But the study showed that even trauma surgeons felt they were less prepared than vascular surgeons to do the [00:22:00] trauma. So is this whole discussion that we're having and the rationale for even having this podcast just really boiled down to general surgeons feeling that this is a, a lost art for them. Uh, whether they're out of training 10, 20 years ago, or they're going through training now and they're gonna graduate and say, gosh, I'm a trauma surgeon. If I need to be able to stop the bleeding, I don't have as much skills as I'd like. Is that really what this is all about or is it two sides? Yeah, I, I think there's two sides of the story. I was involved with that survey and it was really interesting to me there's some professional gamesmanship, right? We've all, we all do it, we're all surgeons. Here. I can talk about the er. They say, well, we don't think, know, think those knuckleheads in the ER know how to manage this, right? So we do that to each other too, right? It's, it's very much a sibling. Arrangement in that regard. Ask any trauma surgeon that, you know, what were their three best injuries in the last year? And probably two of 'em be vascular. Right. So it's, it's a entity [00:23:00] that people are excited about and they, to be, uh, it's dramatic. Uh, it requires the full spectrum of resuscitation, identification, control, technical elements, backend, uh, rehab, and, uh, critical care. But the challenge is how do we get there? They're excited about it. How do we get the general surgeon there? And the other thing about that survey that was interesting to me was a lot of vascular surgeons, all of them universally felt like they were more capable of dealing with vascular gym trauma surgeons. My brain is divided right down the middle of vascular surgeon, trauma surgeon. And I understand that viewpoint, but Brian has probably a very nice, well organized elective, busy elective schedule. And, um, when you throw into the middle of the night on a fairly regular basis. Uh, a an all night case that takes a lot of time and then throws out a, his whole elective schedule. 'cause a, a lot of vascular surgeons are, are aortic centric or carotid centric, as I mentioned, right? So they have other practice interest areas and we're robbing them. [00:24:00] That I think if we can find a way to partner, we alleviate the burden on the vascular surgeon, but we, we utilize their technical expertise that the general surgeons are having a hard time. Uh, maintaining for the older groups and for, and to even grow for the younger folks, and all underlying, this is variables that we're not even gonna talk about, like the proliferation of trauma centers, right? It's not that we see fewer injuries in this country, it's that they're dispersed. Across a broader spectrum of HCA hospitals and, and I'm not slandering any organization, but that's just the reality of what it is. So the reason some of these numbers are down is because trauma care, uh, has been, uh, dispersed a bit more and decentralized, and that's another challenge we gotta think about. Yeah. And that's been proven. There's a study looking at X laps, right? Major X laps in trauma centers. And depending on whether you are a low, medium, or high volume for X laps, and I believe it was 10 or 12 laparotomies a year,, was the cutoff for low volume. Just like [00:25:00] a lot of different types of surgeries we do, the more you do, the better you are at it and outcomes are better when you, do it more often. Hey Patrick, can I ask a question, uh, of Teddy and Brian? So. Teddy, does everybody in your group feel equally comfortable and passionate about VA managing vascular injury operatively? No. No. I think, you know, some of our group members don't have as much interest or the skillset. Um. We are fortunate enough that we have enough redundancy in our schedule that there's always someone in the group. Sure. Ut Houston's a different monster, but I would a, I would say probably any institution, you're could say some, and I bet if I ask Brian, uh, how just do all of your partners universally get out, jump out of bed, and rush to, to see what's clamoring about in the front yard whenever they get called for a vascular injury? So we have a bit of a unique model in that regard, uh, at Duke in that we have four hospitals within our health system and there is an opt-in element to the management of acute care coverage of the level one trauma [00:26:00] center, uh, that we have. So there has been a selection of the faculty that are interested in and, and really motivated by that acute care vascular surgery coverage. Both in the setting of. Management of trauma, but also in the setting of, uh, the other, acute care, vascular issues that we might encounter. Well, and both of you're being good stewards of your institutions and saying, our institutions are awesome. I've been at many, and not all of 'em work that way. You know, there's some vascular surgeons are into it, some trauma surgeons are into it, and on both sides, the other people run the other direction if they can. And so I think the way to move forward is to pull the Teddy PIOs and the Brian Gilmores of the world, and put them on some kind of response team for these vascular injuries. Then you're gonna see the way things can be done and should be done personally. Yeah, and ideally you have enough overlap or, redundancy in your call schedule that you can create that without destroying the rest your home life, your, your, your elective life, et cetera. And that seems to be, a challenge, right? There's only so many folks in each group, and, and in general, you're [00:27:00] operating on the razor's edge in terms of, one person gets sick or needs to go out for, you know, uh, uh, some time and, and then all of a sudden you're double covering and, it can be quite challenging. I think that's probably not unique. In terms of this issue. We don't have a great answer. Uh, we all agree that we need to pay close attention to it and that there's no one size fits all to the problem. And, without a doubt, uh, trauma centers need to do their best to enhance collaboration. To figure out, what works best at a single institution. And, and for any given patient to do what's right for that patient in front of you. They, uh, you have to be ready to offer unique solutions and understand what resources are available to you. And oftentimes that may be a vascular surgeon if you're a trauma surgeon or a unique endovascular approach if you have that luxury. So no one owns vascular trauma. No one owns it. But are there any additional. More specific solutions we can recommend that are more than just [00:28:00] everyone get along and do the best for the patient in front of you. A lot of your audience is probably trainees, right, who are listening to this, and some of 'em are saying, I want to get better at vascular injury. How do I do that? I think you have to take a lot of personal ownership of those opportunities. You need to go knock on Dr. Gilmore's office and say, how can I, can you got some cases I can assist with or. Get in the, or do those things. The skillset acquisition, as we've talked about with the, you know, GME case requirements and even the EPAs, the, it's not built into the system. You've gotta create your own pathway if you're truly interested in improving in this specific area to some degree, right? You're not gonna finish two cases and be a pillar of vascular injury care at your future institution. But if you build that skillset through. Means that you have to get creative with, and you build a network. So when you move on to your other institution, you call Dr. Gilmore, Hey, I got this vascular injury. You know what? What do you think? And there's my va. I don't have a vascular surgeon here, or I don't have one that I feel comfortable with. Now [00:29:00] you've got a network of people working on a problem that's really challenging. And I think that would be really cool. I do think it's an important thing for us to continue studying in terms of what the volume outcome relationship is, uh, with respect to individual surgeons and with specialties. I think that this is gonna be a moving target, not just with respect to, what individuals do well, but what the trend in management winds up being over time, particularly as some of the older generation who may have more experience with and comfort with this management phase outta their careers and retire. Patrick, can I go back to one thing? I would say you should. Be in charge of your own education one of the, things I remember from my residency training, I was at a place that didn't do a lot of vascular trauma, but we did do a lot of fenestrated endovascular cases on vascular. And as a resident, you know, that was not a junior level resident case, right? Like no intern or second year wanted to be in there for all of that. But I can tell you that every time we had an open [00:30:00] exposure. To start that case, I made myself available and so I think if you can tell your faculty and your fellows that like, Hey, I have an interest in vascular and I want to be a part of whatever components that are helpful for you, your skillset, and that may advance as in your in residency. And particularly for the general surgeons listening, what we talked about earlier, exposure and control. That is the key. Certainly you wanna do more if you get the opportunity. Last question is for you, Joe, how many dual trained, uh, vascular and trauma surgeons are you aware of in the United States? And what was your pathway briefly, and would you recommend it? I would not recommend my pathway because I did everything through the military, so I wasn't gonna make any extra money doing anything. I won't go through the math of the 20 years that I owed, but it worked out really well for me to do a vascular fellowship. And I did it after six years of being a trauma surgeon. And it was because. I could see all these cool injuries being done in do by Brian, you [00:31:00] know, and his crew. And I was like, I wanna be part of that crew. And the military was very keen to have one B before they would've to deploy a trauma surgeon and a vascular surgeon. And if I'm one guy with both skill sets. I saved them money, I saved them exposure, so they were very keen to let that happen. That being said, there's probably, I think we did a straw poll and came out to like 13, but there may be 20 or so people who've done both trainings, but the majority go on to do. Not both in, in terms of clinical practice. Some vascular surgeons I know, or you wouldn't even know that they've been trauma critical care trained. It's not part of their identity. Uh, and there are a few that have gone the full trauma route and maybe they just do a few more angios than normal. Um, but people who dual practicing, I know a. Uh, in the country. I, I wish there was one at every major level one trauma center personally, because I think they would be tremendous liaisons between the two worlds and do much to break down the [00:32:00] thicker silos where they do exist. Yeah. Alright. Fantastic. Well, thank you all for joining us today and, uh. This is a problem that we'll need to continue to, keep close eyes on and do everything we can to get the next generation ready to, stop the bleed and save some lives. Until next time, dominate the day.