Pediatric Surgery

In this episode of Front Line Surgery: Mastering Military Trauma Care, hosts Drs. Jeff Conner and Jay Yelon are joined by Drs. Matt Martin and Luke Neff to discuss the critical aspects of pediatric trauma care in a deployed military setting. They emphasize the importance of preparation, improvisation, and understanding the unique challenges faced when treating children in trauma situations. Key topics include initial assessment, resuscitation techniques, vascular access, damage control resuscitation, hypothermia management, and surgical approaches to hemorrhage control. The conversation also highlights the need for military surgeons to be equipped with pediatric supplies and knowledge to effectively care for injured children in combat zones. 

Keywords: pediatric trauma, military surgery, resuscitation, vascular access, damage control, hypothermia management, surgical techniques, deployment preparation

Literature:
ACS M Curriculum: Pediatric Surgery Module

Transcript

SPEAKER_02 0:00

The first question you might be asking yourself is why is there a kid at my forward surgical team or combat sport hospital? If that's an issue, then why this podcast topic's important is because our doctrine has always said we don't take care of kids. We're not supplied for kids, we're not staffed for kids, and every deployment we are taking care of a bunch of kids.

SPEAKER_01 0:23

The whole just little adults when it comes to trauma care, keeping it simple and uh relying on the standard principles.

SPEAKER_03 0:32

Enter the world of military trauma surgery with frontline surgery, where we bring you expert insights and real-world scenarios to help surgeons stay ready.

SPEAKER_04 0:40

Brought to you by the AST Military Committee. Join us as we engage in conversations with field experts, examine critical battlefield scenarios, and uncover the strategies that keep surgeons ready for anything.

SPEAKER_03 0:53

Stay prepared and stage dark with Frontline Surgery, where every episode provides key insights into mastering military trauma care.

SPEAKER_05 1:04

Welcome to Frontline Surgery, Mastering Military Trauma Care. I'm Jeff Connor, an Army trauma surgeon.

SPEAKER_00 1:10

And I'm Jay Yellen, a Navy trauma surgeon.

SPEAKER_05 1:13

In this series, we help prepare early career military surgeons for the realities of deployed trauma care, sharing key insights from those who've been there. Today's episode is a very important one focusing on pediatric surgery and trauma care in the deployed setting. We're honored to be joined by Dr. Luke Neff, a pediatric surgeon and former U.S. Air Force Staff Surgeon with deployment experience in supporting Operation Enduring Freedom during 2013 and 2014. We're also joined by Dr. Matt Martin, a current trauma surgeon at LA County and retired U.S. Army colonel with extensive deployment of experience over his career. Thanks for coming, everybody. So let's let's start with a scenario. So it's you're at a role two in an urban region of Eastern Europe. You're supporting both U.S. forces and a local national population. And a seven-year-old boy presents after blast injuries. There was reported hypotension in the field, and he presents with no vascular access. On arrival, he has an obvious mangled right lower extremity and evidence of shrapnel penetration on the extremities and torso. Dr. Neff, Dr. Martin, you lived through scenarios like this before. What's going through your mind as the patient rolls through the door?

SPEAKER_01 2:24

Where's the Brazlo tape? That's certainly number one. Do we have the stuff we need to resuscitate this kid? So thinking through access, thinking through hemorrhage control with tourniquets and things like that, which are fine to use, you know. I think a general practice principle, and I'd welcome Dr. Martin's thoughts on this, but you know, the whole adage depends on who you ask, the whole adage of little, you know, children are just little adults. I think when it comes to trauma care, keeping it simple and uh relying on those standard principles that you would follow for ATLS or deployed uh combat care, a downrange are the same, whether it's a child or a uh an adult, with some with some caveats, but I'm certainly thinking about Brazlo tape though, specifically with medication dosages and things like that.

SPEAKER_02 3:10

Yeah, the first question you might be asking yourself is why is there a kid at my forward surgical team or combat sport hospital? Right. And and that's that's an issue and why this podcast topic is important, because our doctrine has always said we don't take care of kids. We're not supplied for kids, we're not staffed for kids, and every deployment we are taking care of a bunch of kids. And the papers written on it showed like up to 15 to 20 percent of bed days were for pediatric patients in Iraq and Afghanistan. So that's the first thing. You're told you're it's not part of your mission, but it will be part of your mission. So I agree with Luke. The Brazlo tape, but what that means is somebody hand carried that in, and then also like hand carried pediatric supplies in, and that's what happened in Iraq and Afghanistan. You know, we were there for 20 years and people were able to hand carry stuff in, and we had pretty decently developed pediatric carts, but we certainly didn't at the beginning of those wars. So bring pediatric supplies, bring a brazlo tape, it's a lifesaver, have either a bag or a cart that's color-coded, just like the brazlo tape, because uh again, Luke, Luke is a pediatric surgeon. You will not have a pediatric surgeon with you, most likely, or a pediatric nurse or a pediatric intensivist. So an anything you can have to make your life easier. And for this kid, this isn't that different than an adult. You focus on hemorrhage control first, IV access, which most likely, unless there was an easy peripheral, would be an intraosseous in this kid to start your resuscitation.

SPEAKER_01 4:50

I think uh that's one of the things that that causes me a lot of heartburn, even in our civilian trauma populations, is that we are just not as willing to pull the trigger on intraosseous access, particularly for a child that's not obtunded, right? That can feel and is responsive. We uh we don't do that as much. And I think we need that. That's a skill for anybody going downrange. Being comfortable with that and learning how to use the easy IO um, I think is a really important thing.

SPEAKER_00 5:16

Some of the stuff you both of you just talked about, and I I really appreciate those comments. Let me tell you about an experience that I had. When I was deployed in 2019, I was part of a far-forward Navy single surgeon team. Most of our stuff was in support of special operations, and we were tasked to support a combined task force in which right before the mission went off, we had some human intelligence that there were several children in the area where uh special operations would be. And as Matt alluded to, there is no doctrine talking about children, there's no equipment. So, how do you prepare your team? Let's let's say you either packed a small bag of pediatric supplies, or maybe you don't have any pediatric supplies, how do you pivot in that situation to prepare to deal with that? And I'm gonna I'm gonna ask Matt to comment first and then Luke if you could follow up.

SPEAKER_02 6:23

Yeah, I I'd say one, you look at your resources and who you have. And and even though we say, you know, you don't have a pediatric intensivist or maybe a even pediatric surgeon with you, you know, as general surgeons, pediatric was part of our training. Your anesthesia people, they've done pediatric anesthesia. So there's some experience of familiarity there. The other part is just like we do with adults all the time, is you have to improvise, right? You you might not have uh pediatric-sized chest tubes, but you have, you know, centraline kits or drains or even NG tubes. So you have tubes and things that can be put into places that they weren't meant to. So, so and more so with pediatric patients. A lot of times you're you're improvising and you're using something that wasn't necessarily made for that. I had to do an emergent pericardial drain in a three-year-old with a massive uh effusion and and tamponade, and all we had were central line kits, so I used a cortis kit, and it worked well. But you need to be prepared either either to start start supplying yourself or to improvise.

SPEAKER_00 7:30

So you're you're advocating the idea of thinking critically in a time-dependent fashion. Luke, you want to follow up?

SPEAKER_01 7:39

I think those comments are great. I mean, so much of what we do is, you know, there's so many variations in size and situations that we do a lot of MacGyvering and pediatric surgery, and even more so downrange. As Colonel Martin was talking, I was thinking about this this Navy SEAL medic that was talking about his suction. He takes a 60cc syringe and some tubing, and that's his that's his way of delivering fluids. It's also his way of creating suction. Like he he just found 10 different uses for this piece of plastic. And so I think about Dr. Martin's comments about every instrument's every instrument. You can apply it in a lot of different ways. The one thing I would say that needs to be really thought through is you know, having the right I.O. access because that's something that will not necessarily be a one-size-fits-all situation. But also one thing I think is really critical to think about with respect to children, especially, is gastric decompression. And I'm talking about in the acute moment because, you know, if it's ABC or CAB or whatever you're working through to resuscitate that patient, you will have a can't oxygenate, can't ventilate situation on your hands really quickly when you're bagging a child. And a lot of that starts with, you know, you may have the greatest oral airway and you may have an airway that you can maintain for a while, but once you start getting gastric distention, if you can't decompress that stomach, you're gonna quickly get into a can't can't ventilate situation, then ultimately can't oxygenate, et cetera. So I would say that for, you know, the one message I really want to leave with people is do not neglect gastric distention in a child as a cause for can't ventilate, can't oxygenate. And even after you have them intubated with secured ET tube, if you happen to have one, if that stomach is still massively extended, you're not gonna have your functional residual capacity and you won't be able to ventilate that child well. So that's kind of one of those things that was just amongst the the issues of uh of access and initial resuscitation and airway management, you gotta think about the stomach in these small kids. That's that's a really that's maybe not intuitive to people, and uh, and that's something that you like to consider.

SPEAKER_05 9:49

So speaking on vascular access, I mean, like you guys alluded to earlier, it's a common problem in the civilian setting, the deployed setting. We talked about IOs. What about central access? You know, we're gonna talk about here shortly about blood product resuscitation and and damage control resuscitation pediatrics, but but do we need central access? Do we need, you know, you mentioned I.O. What are some other techniques for getting good access with pediatric patients?

SPEAKER_02 10:18

Luke, what would be your go-to central access?

SPEAKER_01 10:20

Yeah, I think no matter what you're putting in, yeah, it it needs to be, you know, you can use a lot of different things. You can use a big 14 or 16 gauge anti-cast. But the one thing I would say is ultrasound is so key in these kids, especially if you have a hypovolemic child. You know, you're trying to hit a bullseye that's maybe at best five millimeters in diameter if you're thinking about the IJ or the femoral vein or something like that. A saphenus is a great thing if you have the time, but those are a lot smaller. Like a saphenus cut down in a small child is really difficult. The one thing I would say is part of your quote unquote kit is the uh five French micropuncture kits that come with the 018 floppy tip guide wire and the 21 gauge micropuncture needle. That is nearly ubiquitous in terms of vascular access for vascular surgery indications. But the things that make it better than anything you would get out of a kit, a central line kit, is the fact that the uh 21 gauge needle is ultra sharp and it usually has a radio or an ultrasound kind of loosen tip that you can really see well in ultrasound. And that floppy tip guide wire is really helpful. And once you get that five-front sheath in, you pull the stylet and you can do anything you want in terms of getting access, or you can just leave that in and that's your thing. Um, so I would say, you know, if I'm packing to go somewhere, I'm making sure I have a range of of the IO stuff, some some nasogastric tubes that could double uh is you know, chest tubes, et cetera, and then micropuncture access, because then you can do a lot of stuff. And so what if you've got four centimeters of a standard adult central line in a child or you know, whatever you need, so what, right? At least you've got the access. Um, but that five French micropuncture set really helps you and sets you up for success.

SPEAKER_02 12:04

Yeah, we had we had a stack of the pediatric IJ kits, and and those were great for central lines in essentially any age and ephemeral and actually subclavian, especially for the like one-year-old or under that we couldn't get anything, but that was kind of our go-to. But those are those are challenging lines to get.

SPEAKER_01 12:24

The other thing I would say too, if you're just thinking about this or thinking through and listening to this podcast, is I routinely, especially as it comes to IJ and femoral access, I will not have a syringe on the needle. You've got one shot at this. And so if you're doing ultrasound guidance or even blind using landmarks, when you get any semblance of flash, that's the time for the threading of the micropuncture wire. Even the process of removing a syringe from the needle is gonna, is gonna mess you up. So I typically will just uh stick it without a syringe on there and try to get that that flash that I need. Just a style point, but it really helps when you know you've got maybe one or two shots at it before you develop a hematoma that just renders that vessel completely inaccessible.

SPEAKER_00 13:09

Those are some great tips and tricks. So thank you. Let's let's pivot now that we have IV access, let's talk about resuscitation. And so I want to hit on a couple of things. I want to talk about damage control resuscitation in children. I want to talk about whole blood versus component therapy, and then I want to talk about adjuncts, specifically TXA, calcium, vasopressors. Where do we stand on those things? So let let's let's go through them individually. What about damage control resuscitation?

SPEAKER_01 13:44

I think if you're downrange, you're gonna have whole blood, right? If that's what we're stalking, and that's you know, low tide or oh whole blood, even if it's Rh positive, give it, right? We don't have the results of the big Matic 2 study, which is something that's being run out of the out of Pittsburgh by Phil Spinella, a pediatric intensivist in the Air Force, with a, you know, did a ton of work in that in the resuscitation space um and still is doing that. We don't have those results yet, but I think there's enough, there's enough indicators that that giving the whole blood, giving them back what they lost is really important. That would be my first comment. And then with respect to TXA, I'll I'll defer to Dr. Martin because he wrote the paper on TXA and children downrange.

SPEAKER_00 14:24

Let me just before Matt answers that question. So let's talk about the whole blood. So you you do a walking blood bank and you have an adult unit. How do you how do you do it? How do you execute the transfusion in the child?

SPEAKER_01 14:38

Yeah, so it's not gonna, I mean, I I don't know if it's gonna be Lucre reduced or not, but um, you know, in a pinch, you gotta do what you got to do. Uh Rh positive, RH negative doesn't really matter because the allosensitization issues that are kind of the big boogeyman for whole blood are really, I think, turning out to be less of an issue than we thought, particularly for young women. But start out with 10 to 20 cc's per kilo. And I mean, that's just, you know, when it comes to PEDs, the numbers you have to remember are the 421 rule for maintenance fluids. And you have to remember that uh they have about 80 cc's per kilo of total blood volume, which is helpful when you're in the OR and you're soaking up lap sponges, and that uh 20, 10 to 20 cc's per kilo in terms of the boluses that you're administering, whether that's crystalloid or hopefully blood, in the context of resuscitation, those are the important things to remember. And the last thing would be what is hypotension for a child? And generally it's like Ms. Mercury plus two times their age. So if you're a three-year-old, two times three is six, plus seventy is 76. And that's kind of your borderline low level for hypotension to understand that in the context of kids. So that would be my just general principles in terms of resuscitation, the quick and dirty, the things that I think will get you by.

SPEAKER_02 15:52

Yeah, I I think just a general thing is all the damage control stuff we've learned in adults, just apply the same thing to kids. I think the most important thing, especially for adult trauma surgeons, that we very quickly lose track of is the blood volume of that child. And we are used to we finish our case and the floor is covered with blood, and we're like, okay, you know, high fiving. Just remember the smaller the kid, the lower that blood volume is, you know, down to, you know, a one-month-old has about a can of coke, is their entire blood volume. So you can have a couple lap sponges full and some on the floor, and that's exsanguination. That we often, you know, it doesn't often key us key us off as adult surgeons as this is this is large volume blood loss. So so it's just understanding that much less tolerance for how much bleeding you're having. 40 mls per keg is about half their blood volume, right? So 10 to 20 mls per keg is is usually about what you'll start off with for giving them blood products. Yeah, TXA, we we did the PEED track study in combat pediatric patients. We found a benefit of TXA, you know, retrospective data, no signal of harm. So I would give it, I would give it liberally just like we do for adults. And and standard dose. And I think even the TCC guidelines for adults have gone to single dose pre-hospital. I I would just do exactly the same thing for a kid.

SPEAKER_01 17:12

Exactly. Yeah, 25 MIGs per kid, right? Is uh up to two grams, is what we would do for kids. And that's based on some of the stuff with Matic 2. Like, why reinvent the wheel? A lot of smart people have spent a lot of time thinking about this. But yeah, I think that the the Matic 2 trial and its uh you know, its investigation of TXA and its benefits was really influenced by the Pete Strach studies that that were done in Iraq and Afghanistan by by Martin and Eckert. You know, that's that's really important. Eckert in the world context.

SPEAKER_02 17:43

Eckert and Eckert first.

SPEAKER_01 17:46

Okay, yeah, he goes first.

SPEAKER_02 17:47

And then I the only other thing I'd say is remember that kids probably are also more susceptible to circulatory overload from over-resuscitation. So so you also want to be careful about that. You know, once you've hit your resuscitation goals, you don't want to be flooding them with a lot more blood products. And again, you know, we're used to hanging a unit and then another unit and then another unit, and people might not be thinking in the no, you know, this many CCs per kilogram and not run that whole unit or two of blood.

SPEAKER_01 18:20

And a lot of times it's to delivered, uh, especially in smaller children, through a syringe, you know, just literally pulling it back. You have to be careful about how hard you do that to prevent lysis of those RBCs. But um backing up just 10,000 foot view on this whole this whole scenario. If you are hypotensive as a child, you know, a school-age child or even younger, or adolescent too, then you are way behind. The, you know, that's children and little adults, that that adage works up to a point. The reality is that the a child's compensatory mechanisms with heart rate and vascular tone are so robust that until you get to the very, very end of their physiological reserve, they're going to maintain their pressure and you're going to have a false sense of security. I think about uh um, I mean, you get there and you just fall off. Barbara Gaines is is a sort of a luminary in the blood space and in resuscitation and peach trauma. And her comment that she made one time really resonates. Like, if you are hypertensive in a hemorrhagic uh, you know, trauma patient that's a child, you are you are way behind. And that needs to, you know, not just a little bit behind and like let's get on it, but you are about to to get bradycardic and arrest. And uh, so that's something that I think, you know, along with the nasogastric tube, uh, little pearl is uh is a big thing to leave, is that hypotensive children from emragen shock are are about to arrest.

SPEAKER_00 19:51

Can you you guys both comment on hypothermia management for the kids, especially in a roll two setting?

SPEAKER_02 19:58

Yeah, avoid it. Just like adults. Um, they they will get hypothermic much faster, right? They have increased body surface area. So you want to keep them warm even when, you know, you take all the blankets off and have them exposed and then prep and take 15 minutes. You want to keep them warm, you want to turn up the room, you want to use your your uh HPMK, your hypothermia prevention management kit or whatever you have at your facility. If you have any way of doing forced air, you know, warm blanket or bear hugger, do that aggressively. These kids will get hypothermic very quickly.

SPEAKER_01 20:32

Yeah, I think the other thing is having a belly compartment open is just gonna accelerate that so fast. And one of the things that we will routinely do, and this is just a little hack, is they'll anesthesiologists will take a bag, literally a plastic bag after the child's intubated and put it over their head. It's like, what are you doing? You're gonna suffocate this kid, but they're intubated and trying to minimize any heat loss through their head, especially for toddlers and these younger ch children that have a disproportionately large head to the relative body surface area. And then uh using a lot of iaban to make sure that we can keep them as dry as possible. You don't get a lot of fluids that are dripping down around the child that they're sitting in it, because that'll get them really cold as well. So we just try to do stuff like that, common sense stuff to avoid that. And anything you can do from an active warming standpoint is great. Just downrange, your options are probably limited.

SPEAKER_02 21:21

And then don't forget about transport. Transport, it is cold on those helicopters. And if you don't have that child packaged up completely, you know, the tinfoil hat entirely covered, your plugs, eye protection, they will get cold on transport too.

SPEAKER_01 21:39

Yeah, we use as uh the transport, even from the OR to the ICU in our hospital, we have it basically looks like a giant hand warmer. You know, it's a little bit fluffy, but uh it's it's one of those, you know, the kind of you'd put in your in your mittens when you're going skiing. Those kinds of things, thinking outside the box and and employing those kinds of things, hand warmers can be really helpful.

SPEAKER_05 22:00

All right. Switching gears here, just for a second, we've talked about resuscitation. I wanted to get a couple thoughts on the actual surgical portion of this. So when you're approaching surgical hemorrhage control in pediatrics and trauma setting, how does age and anatomy play a role in determining, you know, what what what incision do I make? Is it a transverse laparotomy? Is it a midline laparotomy? Is there an age cutoff? I remember doing this in residency as a as a pediatric uh resident, surgery resident, but can you kind of comment on uh the size of the patient and how that plays a role?

SPEAKER_02 22:39

I'll I'll go first because my answer is the shortest. I'm an adult surgeon. Don't deviate from what you know. Um I'm making a midline laparotomy, if it's a laparotomy. Um, but Lou can expand on that because I know there's certainly other options, but don't go way out of your comfort zone for a kid that's dying of hemorrhage.

SPEAKER_01 22:59

Yeah, I think yes to that, with the one exception that um, you know, for anything less than probably 24 months, you know, if you're over 24 months, that makes a lot of sense. I do think that your exposure, the expansile nature of a transverse laparotomy, and some of these kids that have a bootabelli that's almost like a basketball, you can see everything really well, and particularly expose the liver and other things like that that bleed with a transverse laparotomy. Um, so I think your general cutoff is is uh if they're less than two years old, go for transverse. And it's not hard. I mean, you just have to make sure you ligate the umbilical bane remnant. But that would be my my thing. And and to be honest, like this is a good question because I still struggle with these tweener kids. Should I, what's my best exposure? Uh so it's not necessarily straightforward, but I think uh a good rule of thumb is if they're under two and it seems like uh they have a round belly, then go for the transverse.

SPEAKER_05 23:58

So the other the other thing I wanted to kind of mention or talk about for a couple minutes was limb salvage. Now, in a deployed setting, kids dying of hemorrhage, I think that that, you know, the decision for limb salvage or not, or vascular reconstruction uh is a tough decision. But how do you how do you how do you draw the line in the sand with with kids?

SPEAKER_02 24:20

Yeah, I I'd say we're not often, we're not, in fact, I can't even remember making this decision of we can't get hemorrhage control. We have to amputate because we can't get hemorrhage control of an extremity. Right? We you can always get hemorrhage control of an extremity. So it's very rare you're kind of making this decision of I need to amputate because the patient's dying from bleeding that I couldn't control in that extremity. The decisions are usually is this reconstructible? Is this something I can fix? And what's their long-term outcome going to be with a semi-functional or non-functional limb versus an amputation? Now, the thing to remember, which is counterintuitive, is like for adults, we would often be more aggressive at limb salvage for local nationals, and more aggressive with early amputation for our U.S. service members or NATO allies. And that's because they're gonna come back to the US and get a well-fitted modern prosthetic. And this local national who now has an amputation and they're not gonna get a prosthetic, and you know, they're they're gonna be an outcast from society, they're not gonna be able to work. So many times they're better with a partially functioning or even a non-functioning limb, but still having the limb. And I think those same things uh apply to pediatric patients, you know, local, national kids. I would definitely try to avoid amputation early uh and opt for whatever you can do for limb salvage, and then you can make that decision later. I think I think probably the biggest difference with adults is the management of vascular injuries. And the smaller you get, the less reconstructible those vessels are. Uh, and and sometimes in those settings, you have no option but to ligate. But actually, oftentimes they'll tolerate that ligation. So I'll and I'll let Luke take it from there.

SPEAKER_01 26:14

No, I think uh you've you've hit the nail in the head and said everything I would say, which is you can get away with a lot more than you think in terms of ligation because of collateral flow in these kids. And we know that, at least from the civilian literature, because of iestrogenic injuries surrounding vascular access, you know, you bugger up ephemeral vein and it it turns out to be okay because they can collateralize. So there's that, right? Uh I think that to Dr. Martin's comments, you know, you've presented a scenario earlier where we're in Eastern Europe, and that's very different than being in Iraq or Afghanistan. And I certainly echo his comments about the calculus, the mental math about what is going to be best for that patient long term is highly cultural. It depends highly on cultural context. It is contextual for sure. And so that's where really relying on a lot of your host national partners that understand the culture and the context to help make those decisions, I think is important. Um and uh, I mean, kids are often resilient though. The their ability to to navigate life as an amputee with or without a prosthesis is is pretty amazing. So it it goes both ways, but I think uh that's that's a situation in which I would really rely on host national partners in the healthcare realm to help me understand the clinical context or the cultural context. And uh it's a tough question.

SPEAKER_00 27:33

These have been some uh great points and a great discussion. Let's let's take a higher 30,000-foot view. Uh for surgeons who have yet to deploy or about to deploy, uh what should they be doing to prepare to take care of injured children or care for sick children downrange?

SPEAKER_01 27:59

I think uh in terms of just uh being able to access materials, you know, there's a lot of stuff online. The Pediatric Trauma Society does an excellent job. They partner with the AST and with East to produce guidelines for best practice in the care of an injured child. Some of that stuff is not going to be relevant in an austere or deployed environment because of resources, et cetera, but at least it's a good starting point. So I definitely would point people, if you know you're going downrange and you want to kind of at least have a collection of resources in your back pocket, certainly the Pediatric Trauma Society website, as well as East guidelines. And I think more than anything, having a good head on your shoulders, maybe planning with respect to grab a Braslow tape, grab some other stuff that you might need in your hospital that you think would be appropriate for pediatric care and just have that around. But being intentional about that, I think uh and listening to things like this and getting as much content as you can, those are all important aspects of getting ready. Being a good general surgeon is gonna make you a good surgeon and a pinch to take care of a child.

SPEAKER_02 28:58

Yeah, and I'd say that there's also a pediatric module on the you know, the KSA modules. So you you certainly can go through that. Um and and then utilize your mentors. I reached back to Ken Azzaro, who, you know, was my program director and his pediatric surgeon multiple times with kids that I wasn't sure what to do with. So, you know, usually you have good communication, at least email, often phone. So, so don't think it starts and ends with you. You have resources available to you, and I have yet to ever reach back to anyone and have them say, oh, sorry, I can't help you. Everyone's always very willing, they're willing to, you know, help out with that kind of stuff. And and then like Luke said, bringing pediatric supplies and and the best is if you can reach out to the people who are there already and that you're replacing or joining and saying, hey, what are you missing? You know, what are the big gaps? And usually they'll send you a list and you'll carry a duffel bag full of stuff into theater. And that's how, you know, over two decades we built up, you know, pretty extensive pediatric supplies in Iraq and Afghanistan.

SPEAKER_01 30:07

I think past that too, just one other point to throw out there is is understand the rules of engagement and your your DCSS and what what kinds of things are going to be no-go areas and what they're gonna say no to and yes to. And uh just have a general understanding because I think more than, I mean, some of the the things I think back on and the faces I see are the children that that we had to say no to or we had to stop in terms of of their care because of the extent of injuries or local constraints and things like that. Uh, so having a plan and initiating that conversation before you ever have that patient in your recess bay is really important.

SPEAKER_05 30:42

Well, Dr. Martin, Dr. Neff, thank you so much for joining us today. This has really been a great, uh, great episode of some really great techniques and pearls for junior surgeons and seasoned surgeons heading to the battlefield. Everyone, thank you for joining us on Frontline Surgery Mastering Military Trauma Care. We hope today's discussion gave you practical tools and perspective as you prepare for your role on the front lines. Until next time, stay sharp, stay ready.

SPEAKER_04 31:09

Thank you for tuning into this episode of Frontline Surgery. We hope today's discussion has provided valuable insights into military trauma care.

SPEAKER_03 31:17

Be sure to join us next time for more expert perspectives and battlefield ready knowledge. Until then, stay ready.