Challenging Case Studies in Law Enforcement Medicine

- Welcome everybody. This is the 13th of the webinars for the tactical section. Thank you all for joining us. We're very excited for the attendance on these and glad this one will offer some CME credit. So, if you do want to claim your CME credit, be sure that you email Deanna Harper, it's dharper@acep.org, and we'll make sure that you get your CME credit. If you are gonna go to the ACEP webpage to look at it, it does take several weeks to get transferred over there. So, you might give it some time. Just so, if you're not aware, one of the free advantages to members is ACEP offers a CME tracker that will track both ACEP CME, but if you want a location that you can store all of your CME, you can upload other documents from other courses and store that in your CME tracker, and then it's kept on there indefinitely. So, it's a neat way to keep all your CME records in one spot. So, that's a benefit to members and those who use it find it very helpful. So, some housekeeping items. Again, if you're not the speaker, if you would keep your microphone on mute. There will be several ways to engage and ask questions. You can use the raise your hand option, and I'm sure there'll be a section for Q and A at the end of the presentation. There's also the chat function. You can enter a question or a comment and we'll try and watch that and share your comment or question with the speaker. And, with that, Dr. Wipfler, I guess it's back to you.

- Great, thank you very much, Rick. Well, welcome everybody, and I hope you're able to learn something from the case presentation tonight. Our goal tonight, we're gonna present two main cases and these are gonna be law enforcement tactical related clinical cases we're gonna talk about. And are gonna have Dr. Keegan Bradley and Dr. Brian Springer are gonna start off with their case and I'll be presenting the second case. And we're hoping to discuss kinda lessons learned. As they talk about these cases, think about you being there. What would you be thinking? What kind of decisions you wanna make? What kind of preparation? What do you wanna do for preventive medicine? What's your response gonna be with your tactical medical team or your law enforcement medical support team? And just kind of think about what would you do, what kind of pre-planning, how you're gonna respond to what happened. So, with that, I'm gonna hand over the microphone to Dr. Keegan Bradley and Dr. Brian Springer. And, gentleman, it's all yours.

- Thanks, John, I appreciate that. We'll go ahead and get started. I'll start off with my presentation here. Let's see. And then. All right. And everyone just sees the single slide, right? Okay, all right. So, I know most of y'all know me, I'm Dr. Keegan Bradley. I'm a secretary for this section. I was gonna lead us off with a case that I experienced as a fellow, actually, about going on two years ago now, out in Charlotte in the Carolinas. So, first part, I have my disclosure slide, obviously, no financial disclosures at this time. So, to start the case out, we had an initial call out for a patient, known felon, and it was kind of a, hopefully, just him in the house, but we were gonna go out, try and get him out there. We went along the street and I'll show y'all kind of how it got set up in the beginning. Cut off both ends of the street, and then both kind of portions of where he could, potentially, run from the house. Once we had arrived, law enforcement had already set up kind of where they were gonna be. So, we staged with the tactical team.

- [Brian] Hey, Keegan?

- Yeah.

- Hey, your screen is frozen. It's sitting there on the first slide. You're getting the little spinning donut of death.

- Oh, really? Okay. Yeah, people may have to, is it doing it now?

- Yeah. Yeah, we've got your whole screen up on there and it's just stuck there on that first slide with the donut.

- Let me see. New share maybe? Here, let's try that. Now what do y'all see?

- Oh, we're now on your arrival slide, so you may wanna back it up a couple.

- Okay, perfect, all right. There we go. That working now?

- [Brian] Yeah.

- Okay, perfect. So, another missed, it was just basically kinda summarizing what I said. Going for a kind of a snatch and grab on a known felon. We arrived with the tactical team, set up just south of the house and both ends of the street, and then both sides of the house and the neighborhood were cut off to not allow any escape. So, this was kind of what it looked like from bird's eye view to give you an idea of where we were working from. The blue cross was our team. The circle with the red X is the tactical team and the armored vehicle. And then, the red X's are kind of where the main positions were that law enforcement took up. So, plan was have the BearCat drive up, surround the house, quarter it off, and, hopefully, kind of wait the guy out. Hopefully, he was gonna surrender and come out. So, as we're waiting out there probably 20 minutes in, we get a call for medic up. So, as the tactical unit approached, they set up positions around the house and we got a call that we needed to come up. One of the sharpshooters was down. We hadn't heard any gunshots yet or anything, so weren't quite sure what had happened. There was just a lot of kinda commotion with the truck pulling up initially. So, you know, you never know what you may not heard. So, they pulled two medics as well as myself, the on scene physician, up. And we had a team escort us up to where the operator had been moved to behind a fence in between two houses. So, it wasn't too far from the actual location, that they had quartered off. When we approached him, we didn't notice any gunshot wounds or anything, we were behind cover, but we brought up our equipment, got an initial set of vitals. We found a 41 year old male. He was pale and diaphoretic, still conscious, still talking to us, feeling very lightheaded, low blood pressure, heart rate was slow for his blood pressure and, you know, he was breathing a little fast, just kind of saying he feels really lightheaded, wanted to pass out, BGL was okay. So, he said he was trying to climb over a fence to try and get into the position he was going to, and just became suddenly lightheaded and went down, but did not pass out. So, kind of quick things in the field, what we did, we, you know, did a quick assessment, didn't find any blood on him, no obvious trauma that we could see. Raised his legs, trying to get a little bit of blood pressure back. And then we kind of carried him about a hundred yards back to the medical unit down the street 'cause they obviously couldn't pull an ambulance up the street there. So, we did a 12 lead and this is what we found in the ambulance. It was concerning for a potential anterior STEMI. So, he was still having some mild chest pain, still kinda diaphoretic, so we gave him everything he needed there. In route, he told us he's a hypertension patient, hyperlipidemia, did have a history of coronary disease, but never had a MI or anything. Not a drug user, no smoking and not really prolific alcohol use. On typical medications you'd expect. So, we called in ahead, activated a STEMI, let the hospital know. He was brought in the ED and quickly transported up to the cath lab where they found an acute occlusion of his LAD and they put a DES stent in him. So, quick but effective. It was, you know, not what we expected when we went out that day to be. We were going out to get a felon out of a house and ended up treating a STEMI. So, just kind of the takeaways from my case. It is a stressful environment, so it's always, you know, you can kind of think of it from a heart standpoint as a perfect time for a stress test. You're jumping over things, running around, you've already got adrenaline rushing on a lot of these operators. So, and unlike the military, you know, a lot of these guys, as you know, are not all you know, 18-20 year olds, you know, in peak condition. Some of them are able to stay on the team quite a while. So, it's not uncommon to have 30, 40, you know, even 50 year olds. So, you know, while it is rare in the tactical environment to encounter these things, it's something that you should not ever forget. It's still out there, it's still possibility. And while most officers that have issues with this are not operating in the field, it is something that's still very common. So, it's always something that should be on any physician in the field's radar. So, and it also kind of hits home that, you know, there's always gonna be a place for an advanced medical provider in the field. Stuff pops up, not everyone in the tactical environment only gets shot and stabbed. There's all sorts of things that can happen. So, I think, you know, there's always use for us outside of what, you know, you see on the news or you see in the movies. So, yeah, it's kind of a quick clean case. You know, you could use this for almost any diagnosis, it doesn't have to be a STEMI, it can kind of be anything you can think of with people, just common medical ailments we deal with daily, but it still can happen in the tactical environment.

- Yeah, I wanna chime in here with a little bit of commentary. And then, I also just want to just talk about sort of in terms of what my own experience has been in terms of dealing with heart disease as it affects law enforcement and as a law enforcement medicine professional over the years. So, actually, if you go to the section website, Dominique Wong put together a really excellent overview talking about the issues with heart disease among law enforcement and looked at data from the Officer Down Memorial page. Now, this was from 2019, pre-COVID and, obviously, COVID has drastically affected numbers in terms of mortality and, obviously, law enforcement as well as many other professions, but looking at 2019 data then, heart attack, so listed as a heart attack, was the fourth leading cause of death among police officers. So, they're just behind, you know, gunshot wounds and motor vehicle collisions. And also, again, sort of represented particularly at this time was actually cancers related to 9/11 as well. But, still, fourth leading cause of death. And that's huge. The average age was 44.8. Now, that's mature in your law enforcement career. Certainly, it's not you know, some of us would say, well, that's only mid-career right there since we're still kind of chucking along with all of this too. But 44.8, I mean, that's still, you look at that, that's actually pretty damn young. You know, the range was from age 30 to age 68. But when I see that average age of 44.8, i.e., more than 10 years younger than I am, that's pretty terrifying. And we should all be kind of terrified about that. Really, what it tells us, if you look at these stats that if you are involved in tactical and law enforcement medicine long enough, you are going to encounter, directly or indirectly, issues among your officers or your cadets that are related to heart disease. And as much as we need to know how to, you know, apply tourniquets, as much as we need to be training our officers to go ahead and apply tourniquets and pack wounds and stop bleeding, we need to make sure that they recognize when somebody has collapsed secondary to a coronary event. They need to know how to deliver quality CPR. They need to know how to apply and use an AED and that they need to go ahead and to do so rapidly and then facilitate rapid transport for these patients. For me, personally, 12, actually, I think I have to take it back, 13 now, years ago, I was out at SWAT school at the Ohio Peace Officer's Training Academy. It was day one of what was gonna be a long hot week in August. And the course started by going and running officers through basically a Cooper standards fitness test. And we had a 32 year old officer, again, so fairly experienced guy, was relatively new to SWAT so he was being sent out there to SWAT school who does not complete the run in time, just kind of struggling to complete it and comes off the track and comes up to me and is like, something's wrong. He says, I'm a runner, I don't know what's going on. And I'm talking with the other instructors thinking, huh, all right, must be heat exhaustion, something like that. So, we have him go ahead and sit with his partner under a tree. I'm like, just go sit and cool off, tell the partner, just keep an eye on him and let us know what's going on. And, less than a minute later, she screams get over here, get over here. And we go running over and he is unresponsive. He actually had a thready pulse at that time. Again, I was thinking, well, more along the lines of what was this, what's going on here? Is this heat illness, something like that? I get my medical bag, throw in a nasopharyngeal airway just to go ahead and make sure that he's breathing okay. Like, hey, call 911, we need to get a medic over here right away. And then I take a look at him again and he is now agonal breathing. And that's when we knew he's now in arrest. One of the instructors who I was with, who is basically, and if you'll pardon the expression, built like a brick shit house, I look at him, I go, go compressions. And he was, it was like having a human LUCAS machine. This guy was absolutely amazing and effortlessly starts going and doing great compressions. Two other officers in the class, young guys who had like ran around the track, you know, effortlessly and smoked everybody else, I turned to them like, get me the AED. And they ran to the building and had it back in the blink of an eye, these guys flew. And so, I had the pads slapped on this guy. And, really, it was a matter of a couple of minutes, tops, and it advised shock. We shocked, we continued another round of CPR, at that point, the ambulance was pulling up, and we checked and he's got a pulse. He gets flown to the Ohio State University. And, I mean, he's still pretty gorked out at this point too. 24 hours later, so it's now the next morning, so anyway, all said and done, I mean, it's still, I went out, I actually flew with him out to the hospital. It's later that evening, I'm actually back at the OPOTA campus going, oh my God, what the heck just happened here? The next morning, get up, and my cell phone rings and it's him, and he says, hey doc, thanks for saving my life. Actually, subsequently, talking to him afterwards, he doesn't remember that phone call or anything. He was pretty out of it with everything. And every year now, on that date, he still reaches out to me and you know, says, hi. And I just a couple weeks back got my sort of annual little text from him, a video of his kid saying, thanks for saving our dad's life and stuff. So, you gotta be, I mean, this was the stars aligned here. This was team effort as far as everything just working out well. Another episode that occurred when we did not have a medical provider was about 10 years ago. Narcotics officer here in my part of town was out serving a warrant, started having chest pain, just feeling kind of ashen and just poorly. Initially, typical cop fashion, being stubborn and not wanting to go to the hospital. Anyway, the other officers finally convinced him to go and, sure enough, he was having a myocardial infarction. He did okay. This subsequently prompted the narcotics officers to approach me and say, hey, we would love to have you or any of your SWAT guys, or even your resident physicians with us, even when we are serving narcotics warrants. We don't know what is going to happen. And I'll also tell you that, since that time as well, they always have an AED with them whenever they're doing any sort of warrants. Last case here, which is, again, something that I was not present at, but at the, this was now about just about three or four years ago, just pre-COVID, police academy, same one that I attended, a cadet is running on the track, I don't remember if this was actually, I don't think this was their actual final one for the academy, I think they were just running a practice timing to see, is getting near the academy to see if they would make it, and a cadet who was in his early forties, so an older cadet, but he collapses cardiac arrest at the track and there is no AED present and he dies from his cardiac arrest. So, again, this is something where, again, it's gonna touch us directly or peripherally or all of the above. We have to be cognizant of issues in terms of heart disease and we have to make sure that our officers are as well. And any questions, comments for myself, or for Keegan?

- That's some great information. I really appreciate both of your comments on, really, the preventive aspect of being there with the right piece of equipment. You know, CPR is great, get it started early, but the AED, or lack of the AED, is definitely a game changer. And, personally, about 10 years ago, one of the doctors I worked with, he had a 27 year old brother who was a police Officer Down in Florida, I don't know which county it was, but, unfortunately, he tried out for the SWAT team, the day that he was actually trying out for it they were doing a pretty aggressive physical maneuver running around and, you know, there's a certain bar there and you need to be physically fit for it, this guy was in great shape and he collapsed. There was no AED and by the time the ambulance showed up about eight or nine minutes later, the shock was delivered, but it was too late. He did not survive. So, this doctor friend of mine has lost a 27 year old brother because of the lack of a $2,000 piece of equipment. And so, that's preventable.

- We do have a question. Yeah?

- Question for Keegan, if I may. In that first case, what did you actually have to get the EKG with? Was that off an AED or did you have a portable monitor?

- Yeah, we had a LIFEPAK with medic as the EMS service out there and they were on standby down the road. So, we had a LIFEPAK we were able to get the 12 lead on.

- Okay, is there any other questions for Dr. Bradley or Dr. Springer? If you do, we'll have time later on to also ask questions, we'd come back to those cases there. So, if it's okay with everybody, I'm gonna go ahead and roll onto the next.

- I think Dr. Kelly has one.

- [Dr. Kelly] Yeah, thanks.

- Go ahead.

- [Dr. Kelly] Dr. Springer, I was just curious, you mentioned when you first started off talking about some of the data around cardiac disease and kind of the attack the law enforcement community being around kind of a little bit younger around the age of 44, I guess. Is there a good source for that information if I wanted to share that with my team that you used or something that, potentially, is on the website or something like that?

- Yes, yes, yes. Again, actually, I got that information from Dr. Wong who had posted that on our section website. So, take a look there. And then, that information came from the Officer Down Memorial page. Which is a really, really good resource.

- Sorry to come on late and in such a spotty fashion, I'm technically working, but the Officer Down Memorial page not only has the broad statistics and heart disease ends up being one of the top three line of duty deaths for law enforcement officers, but they actually give you the age breakdown, which is stunningly low. And if you look at the spread of the age breakdown, even more shockingly low, and in a lot of the cases on the Officer Down Memorial page, they will give you the circumstances. So it'll be, it happened during a training, or it happened that evening when they went home. So, you can get, not complete data for every one of those cases, but quite a bit.

- Great, excellent question. Any other questions? Okay, well, thank you very much, Dr. Bradley, Dr. Springer. We'll go ahead and roll on the next case. I'll go ahead and share my screen here. So, this is gonna be a case that involves our tactical team locally. And this is a case review. What I'd like to do is go through a step by step, gonna show you a quick couple minute video of what that actually looked like at the scene. And we're gonna do is talk about some of the thinking, some of the process went through, how we dealt with the situation and were able to provide advanced quality life support and interact with the trauma team at the hospital. So, anyway, so this is the ACEP financial disclosure statement. The individuals in control of the content are listed there. It's Rick Murray, myself, Keegan Bradley and Brian Springer. Also, Dominique Wong helped out too. Disclosure of financial relationship. There's no individual with control over the content of relevant financial relationship to disclose. And the third component is a disclosure of commercial support. We have no commercial support was received. So, moving on to it, the case review back 2013 Peoria Police Department's SRT, Special Response Team. We were actually in process of training that day. Couple days before there had been a murder in town and they'd been looking for the murder suspect. And we were actually training a couple days later and, right in the middle of our training, got activated. They found the suspect's car. We actually came back to town. It was nearby his house. So we thought, well, if his car's here and this is a couple blocks away from his house, maybe he's back in his house now. They had actually searched his house before, wasn't there, but he was there, potentially, then. So we activated the team, went from the training, we put away the Sim guns, went to load up with the real weapons and went to the site. Interestingly, that actually happened just yesterday. I was training with the different squad team yesterday, and we actually, right in the middle of training, we had to convert and went over to a domestic barricaded suspect with a hostage that was resolved yesterday peacefully. So, anyway, so you take a look, statistically, what percentage of SWAT call outs end without anybody getting hurt? Answer, about 95%. But, unfortunately, about 5% are associated with casualties and harm to the people involved. So, the background, a little bit about my background, I've been a professor of emergency medicine at University of Illinois, College of Medicine. Got about 14 years in Army Reserve Medical Corps. Ran Life Flight for about four or five years and been working with ITOA, the Illinois Tactical Officer Association since 1996. Been a sworn LEO since 1997. In 1999, we worked with some good people to form up the first residency training tech med rotation in our area, at least. And, since then, each year we have about 90% of our residents to go through the tech med over the course of the three years. So, we have two of the two week collectives each year. So, anyway, and honored to work with a good bunch of good people with ACEP section to work on a textbook and got that out. I'm very blessed with the wife, six kids. And then, when I'm not doing the tech med thing, also like to teach tactical emergency medicine, also wilderness medicine, mountaineering and a little scuba. So, this is a one of the mountains we climbed a couple years ago. Hopped into our backpacks and hiked up and stayed overnight in a beautiful spot. Climbed the mountain and hiked back out. So, nice three day trip. Anybody been out to Colorado, this is Crestone Needle, Colorado. It's about 14,200. Supposedly, like the sixth hardest 14'er to climb. And we basically, that morning, day two, we climbed up the base of it and we were roped up all the way through to the very top and then all the way back down. So, we wanted to do a family event, get together, rope up on a 6,000 pound rope and then go to the top of mountain there. So, going down is actually a little bit more hairy than going up, as usually is a case. Okay, this is a view from the top of it. So, beautiful mountain, beautiful place. Get a chance to get out there in Colorado, do some mountain climbing. So, back to our tactical team deployment, what happened was lessons learned. So, the scenario, basically, is a murder suspect, 40 year old male, location uncertain. His car is near his home. Is he in his house? We don't know, we're gonna go find out. So, what's the plan? So, how do you safely figure out if somebody's actually inside a house or not? And he had committed, the potential, he's a suspect, to use a firearm. So, he is armed and he might be in the house. How do you find out he's in there? Well, this is a team forming up a couple blocks away. Stay out of visual range of the house. And we formed up. What's a good piece of equipment, if you're gonna go up close to the house, what's a good piece of equipment to have with you? Answer, so I'm just gonna stop bullets. And so, this is the BearCat, and move my mouse here, you see mouse, the Bearcats over here. We're loading up, popped in there, we went up to the team, went directly up to the front of the house. And here it is pulling up front of the house. Nice up and close and personal there. And there's the house. The team got out, went up. And what we wanted to do is get the robot, the remote control camera, to help clear as much of the house as possible. I'm gonna show about a two minute video of the experience of putting the robot in position. Once the robot went pretty far into the house, there's a little bit of radio communication issues. Those people work that tech team will find that once in a while. Here's the video of the deployment of the robot.

- [Officer] So, John, you wanna stay here 'til we get the first floor cleared or what we can? Just give me coms on it. And then, all right, you guys ready to move up? Just the handle facing out. Watch yourself getting out. Grab your eyeball cameras too. I mean, we've got some right there. That's what's in that little. Oh, you got, you guys do have some, yeah, that's that little. Yeah, I didn't think, I just grabbed what he asked for. Didn't even think.

- [John] There's the robot being carried up the steps about to be put inside the house. Now you're the robot going through the house, looking for things to watch out for.

- [Officer] May wanna come out here and peek in the front window.

- [John] So, the robot was used successfully to search most of the main floor, went up, searched the second floor, and then we went in the basement. When the officer was able to get the robot in the basement, they actually saw something in one of the back right floor bedrooms. So, this is looking at the front of the house. Towards the right hand side, there's a little bit of an alley on the right hand side. You can see that. If you walk down that alley, on the far back right corner in the basement, that's where the suspect was. The robot first saw feet sticking off the end of the bed. We used a just noise flash distraction device to kind of wake him up, see if he was awake. And he did wake up. And the first thing he said was, don't come in here, otherwise I'm gonna shoot myself. I have a gun, if you come in here, I'm gonna shoot myself. And, hence, began about five hours of negotiation. So, here's coming around the corner to the right, you can see here the door to go down this door into the basement, the bedroom is to the right. There's a brick wall there. And he's in the corner, literally, of that room. And we could not really see him until, later on, we introduced a camera, an infrared camera up into the corner of one of the windows in the basement. We're actually able to visualize him and actually see him. So, anyway, so this is the team there. So, we started negotiations. He said, don't come in here, I'll shoot myself. So, we set up a perimeter, activation time about 1:30 and negotiators got there and got to be sunset, got to be dark. We got hungry, we ordered some pizza, got water. There's a bathroom in a nearby house. We utilized that, set up for the duration. So, this picture here in the left is actually looking out into the basement. And in order to protect the negotiators in the basement with him, they had set up four ballistic shields there. And so, that was performed and they stayed there until the end of the excitement there. So, this is darkness, we had a advanced life support ambulance that was set up nearby, and they basically are waiting for a potential patient there. So, anyway, so we're gonna do now is take a look at what happened and the rest of it. So here's looking into the basement. If you see my mouse here, there's actually, there's where the suspect's knee is here, legs, lower legs, so he's laying on his side. Heads up here, the body's here, the lower legs here. His feet are down this direction. And he's holding a gun. He's actually pointing to the gun to his chest. Intermittently, he'd hold it up, point to his anterior chest with one arm and he'd lay it back down. A little bit later on, you'd see him move to hold it up to his chest again, lay it back down. And we used negotiating and the negotiator trying to get him to the surrender. So, here's another picture close up. His heads up this way, the pistols right here, and this is the right leg of the suspect laying right like that. So, we're watching him. And, after a little bit of time, while watching him, we noticed that he actually was holding the pistol with two hands. So I said, hey, heads up, guys, your guy's holding this pistol with two hands. And the SWAT, about five or six of the SWAT guys came around to the camera. Were looking at the camera, the screen of the IR camera. We're watching it and he holds it up there. All of a sudden, we see this bright flash off the end of his pistol, and we hear a noise. There's a muffled shot. And we knew at that point in time, the time to eat pizza was done, it's time to get to work. So, gloves came on and we went to work. So, what do you do in that situation? He's in the basement. You're literally 15, 20 feet away from him. You hear a shot. You know the way he's holding the gun is actually into his anterior chest. What do you do? What's your plan gonna be? What's your pre-plan, what's your role and how are you gonna provide medical care? So, the tactical team responded, we actually performed and they did exactly what we had pre-planned. What they did, as soon as the shot was fired, they waited just a little bit, they threw a noise flash back, the noise flash distraction into the room, banged it. They went in there with the shields. They pinned him down, took the pistol away from him, handcuffed him, and they picked him up. They brought him up the stairs and put him onto the ambulance cart which was right outside, just literally about five feet next to the basement door going to the basement. We placed him down, assessed the situation as a medical provider. The scene was safe, his hands were cuffed in front. No threat there. And, basically, checked pulse. He was unresponsive, had a very weak pulse. At that point in time, we said, let's go, let's move. And we rolled him down the street about 40 yards to the ambulance that was out of the line of fire and loaded him up. So, in the ambulance, once we got him in there, I checked the pulse again, he had no pulse. So, he did have some blood on his shirt directly in front of him, overlying his heart. And we started him rolling to the hospital. What is the medical care you wanna provide at that point in time? You wanna stop? You wanna intubate him. You wanna do an advanced airway? What are you actually gonna do at that point in time? So, those are some things to think about. So, moving down the road, this is the press, or the press was there just like usual with a long call out. This is a view from the TV camera crew that actually took this video. They're about 150 yards away, but they zoomed in. If you take a look here, this is the stretcher right here. And then, here's one of our tactical paramedics. Another one of our tactical paramedics over here. There's me right there. Notice, we have these blue things on. This is before COVID, okay, but this is a traumatic penetrating chest trauma. That's one of the highest chances of getting HIV or other infectious bloodborne pathogens is when they cough if anybody's shot in the chest. So, goggles on, mask on to cover up nose and mask. I notice that it had everybody here up close. They passed those out to our medics. We rolled down, put him in the ambulance. So, once we got in the ambulance, he had no pulse. So, we're four blocks away from the trauma center. So, we pulled up going to the trauma center. The medical care provided en route was simply chest seal on top of the bullet hole and his left anterior chest. And I did that kind of prevent any type of a, you know, the decreased chance of tension pnuemo to get the air out there. I knew I was gonna be doing chest compressions, so I didn't want blood squirting also. So, it'll make more effective CPR if don't have a bloody chest. So, to wrestle chest seal put on the chest, CPR, did bag valve mask, ventilation with the oral pharyngeal airway. And we got the trauma center, rolled in. And, as soon as we rolled into the trauma room, the trauma team had been basically on standby for quite a few hours and they basically went to town. So, here's the trauma team resuscitation. At that point in time, we had no pulse. We put him on the table and the assessment was done. The trauma residents, we had two residents and an attending there, and they basically assessed him. And they're trying to figure out what's going on. And we clearly said, this guy was talking to us 'til about two minutes ago. He's self-inflicted gunshot wound, small caliber pistol, and it's time to crack his chest. It was said politely. And they basically assessed the lungs. There's a little bit of delay. I reached over, grabbed the ultrasound, put it on a gel, put it on direct line on top of his heart. You could see massive amount of fluid around the heart. The heart itself was pumping frantically and it was actually pumping fairly well, but just wasn't really moving much fluid at all. So, there's a cardiac activity and there's a PA type of monitor, but no pulse. So, they basically cracked the chest, opened it up, and there's pictures of the team going into action there. This is a picture of the thoracotomy. Emergency thoracotomy was performed. They opened up. This is after the, they had a little bit of action happen there. As soon as they opened up the pericardial sac from the emergency thoracotomy, the problem was he had acute hemopericardium. Well, as soon as you relieve that, very quickly without a whole lot of blood loss, his blood pressure went to normal pretty quickly. And, when the blood pressure went to normal, it started perfusing his brain. And what did he do at that point in time? Yep, he actually woke up. Opened his eyes up and started sitting up. And the surgeons were not quite very happy with that 'cause their patient was waking up with them with this condition like this. So, basically, they used a rather loud voice to say, don't let him wake up. And I had to look at him and I said, it's a little bit too late for that. And so, we promptly gave him Versed, and we gave him some other medicines, did an RSI, finished up the intubation and we basically stabilized him. He had a hole in front of his heart directly in front. And he also had an exit on the posterior aspect. Surgeons, very good job, a good team effort. They closed off the blood flow, they used their fingers, proceeded to go ahead and use suture to close the holes. Stabilized him, put chest tube in, closed up his chest. Took him up to the operating room where they cleaned things up and placed a more formal chest tube. And that was what he did there. So, the situation there, to summarize it, self-inflicted gunshot wound with this pistol, something like this, wasn't his exact pistol, but 25 caliber Raven pistol. It went into his left parasternal area and through the RV and LV. Single entrance, no exit wound. The bullet was located in posterior chest. Lost his pulse and, very quickly, chest seal, CPR, bag valve, mask ventilation, oral pharyngeal airway. The four block one way, four block the other way to get to the trauma center. And then, the trauma team present on arrival. Emergency thoracotomy. Return of pulse casualty was awake after pericardial sac was opened. Did RSI sedation to the OR. Nice thing about Versed, as most people know about it, if you give six milligrams of Versed, it didn't really affect his blood pressure too much, 'cause he really hadn't lost a lot of blood. The second thing it did was it actually erases your memory for the previous 15 minutes. So, hopefully, and I never interviewed him about it, but I don't think he remembered any of the events in the operating room, which is probably a good thing. So, anyway, so this is another picture from it. There's the trauma team, great team effort. Great trauma team working together. Excellent nurses, X-ray techs, everybody team together. So, casualty outcome, he got stabilized and then he's remitted to the surgical ICU. He had police guard there, of course. 21 hours later, he was extubated, he was awake, he's talking, drinking clear liquids. I dropped by to talk with the docs and nurses taking care of him. Actually went into the room, just talked to him real briefly. Did not mention any of the previous days events. But he did ask something for me. He asked me, hey, is there any way you can have the nurses bring me a cheeseburger? So, I'm thinking like that's pretty impressive. Guy shot himself through the heart and, 21 hours later, he was asking for cheeseburger. So, that was a pretty good team effort, I think, for getting that status there. So, no known to medical complications, neurologically intact afterwards, he went through the criminal justice system after that. And, of course, the news stories are out there about the police, medics and everything. So, the key points here I'd like to summarize here, there's nine points. Number one, the medical pre-planning, the medical threat assessment, figure out what you're gonna do. We had talked with the tactical team and said, hey, if he shoots himself, don't bring us in the basement. If he shoots himself where he's pointing, he needs to be taken out there quickly, put him on a stretcher and we'll get to the hospital for rapid transport time. And that worked out very smoothly. Secondly is the immediate use of shields and going in disarming him, cuffing him, extracting him out, making sure the scene's safe. So, that's before you're gonna do medical care, tactics making sure the scene safe, team is safe, and make sure you're medical people are gonna be able to do your job without, you know, unnecessary risks. Number three, a TacMed assessment, interface with EMS, transportation. We undoubtedly talked with the transport team, advanced life support providers. Very smooth interface, worked out really good. So, short extract, evac, transport time. It always helps pre-notification of the trauma team they're standing by. They didn't like the fact they were standing by for five or six hours, but that's the way it is. And they weren't actually physically there all the time, but they had a couple of team members down in the ER ready all the time. So, the coordinated efforts in the ED. Just a minor delay in the ED thoracotomy. Used an ultrasound to prove to the team that, hey, there's actually a heart there and it's actually pumping, so let's get this thoracotomy going here. And that worked real nice, coordinated efforts. The self-inflicted penetrating cardiac trauma tamponade. If that happens to, you know, either an officer or a suspect or a hostage, we do the best we can, provide the best care for them. And successful resuscitation of a suicidal suspect. The challenges, the team, a couple of officers were kind of kidding me, poking me in a ribs, saying, hey doc, you know, next time don't be in such a hurry to fix them, you know. And my comment to them, we just laughed about, they're just kidding me. But I think the neat thing is that they understand the fact that having closeup medical support means that if they were to somehow pick up a piece of shrapnel or piece of bullet or something through their heart or someplace critical, maybe with that closeup medical support in a good integrating team, that they can actually increase their chance of survival too. So, that's kind of the take home lessons there. So, tactical medicine, it does help with mission success, which is resolving crisis with as few injuries and deaths as possible. Good teamwork and a little bit of luck save the suspect's life and showed the capabilities and benefits of law enforcement medicine and tactical medicine units. And officers have further proof that if it should happen to them, their odds tips in their favor. And the bottom line, at the end of the day, is this. It's gonna improve the odds of everybody going home to their family. And thank you very much for your attention to that and remember to stand ready and stay safe. So, that summarizes the presentation there. I'm gonna go ahead and take it off of the share's screen here and go ahead and open it back up for any questions or comments.

- I'm not sure where the button is to raise my hand for a question. So I'll just, actually, just quick comments here. Actually, that's a really interesting point about using Versed as your sedative medication. I mean, I probably, if this was me, I think, initially, just based on sort of my practice, my go-to would've been to use etomidate just 'cause, again, I'm very familiar with it. Good in terms of, you know, a lack of hemodynamic effects. But your point about the amnestic effects of Versed, especially particular to this case, that's definitely well taken. And you know, you hear about, you know, experiences with patients who are in the emergency department and being intubated and paralyzed and stuff and are actually aware or still have memories of it. So, anything that would've helped wipe out the memory a little bit, that's definitely something I'm gonna kind of file away there in my back pocket should I encounter something like this. Also, and I'm sure while the officers were probably like, oh yeah, all right yeah, nice work saving this, you know, mop's life, but that's still the optics are good. And the optics end up being good for those officers in that team in terms of their professionalism and their ability to go ahead and solve this problem and, ultimately, have this individual come out alive on the other end. So, that was great work by all involved, you, especially, John.

- Oh, thank you, it's definitely team effort there. And, you know, where our hospital is supported by the OSF and you know, they have a neat poster on the wall going into the hospital and basically it's Jesus saying this, quote, unquote from Jesus. It says that what you do unto the least of me, that what you do unto the least of us, you do unto me. You know what I mean? But you got do the best you can and let the dust settle where it may. Sometimes you're at work, sometimes not. So, I don't know if Dr. Wong is still there. Dr. Wong is gonna help comment on this too. She may have had to step away for a patient care there. Do CPR on somebody there. But, oh, that looks like she's there. Go ahead, Dr. Wong.

- Yeah, I'm sorry, I did have to duck out for a minute. So, I caught part of that. But I wanted to say, I agree wholeheartedly that that is part of our role, right? We take care, that's our role. We take care of everybody as need be. So, somebody else's role to judge and convict and whatever. But that is a crazy case. So, how did you transport him, John? Oh, you're muted.

- He was picked up and carried up by two officers. Luckily, he weighed about 150 pounds. Two officers carried him up, put him on the stretcher. And, at that point in time, we strapped him down, moved quickly down the sidewalk. And once we got him to the ambulance picked him up and rolled him in there. We hopped in and, you know, sometimes the paramedics will actually stay right there for several minutes while they get their EKG leads on and they get things stabilized and get a blood pressure and all that stuff but, luckily, we had pre-planned it. We said, hey, if we need to get this person, if we come out quickly and we're rolling quickly, again, don't go too fast, but fast enough to get there fast, but we put him in there and the paramedics said, we already pre-planned this. Like, we're gonna put him in, lock him in place, and we're just gonna go and we're not gonna worry about EKG attachments or anything like that. We're gonna have penetrating chest trauma. If you lost his pulse, we're gonna need to get a trauma room quickly. So, we basically have him strapped down with like three straps and bag valve mask, ventilation and chest CPR, did CPR myself just to make sure good quality chest compressions. And, literally, probably 45 seconds, 50 seconds later we actually pulled up in front of the trauma room doors and got out continued CPR all the way through there. And it is interesting going in the room because I had on a helmet, had on a blue mask, goggles, had a camo outfit, had my Glock 34 with me. And I'm basically telling, you know, that we got a 40 year old male who's self-inflicted gunshot to his chest. He was talking to me two minutes ago. We need to crack his chest. And the trauma team, and especially the trauma attending and the resident, they did not recognize me, did not know who I was. There was like, what do we do with these guys? And I was also accompanied by the two other paramedics who were also in camo also. So, it was quite of a shocker to them as soon as we rolled into the room. I think they were taking aback a little bit about the sudden overwhelming presence of, you know, five or six officers. Behind us, was actually several other officers too and they still had their long guns on them. So, that was a little bit of shocker, I think, for the people there. So, does that answer your question?

- [Dr. Wong] Yeah, it does, definitely. How much notice were you able to give? Obviously, just seconds worth of or minutes worth of notice. So, did you call ahead? How did the trauma team know you were coming?

- Yeah, established talking with the trauma center as soon as we saw, heard he's in the basement, he said, I'm gonna shoot myself if you come in here, that precipitated a phone call to the trauma team and talked to the charge nurse and I said, hey, here's information I need you to convey to the trauma team. They should have several people down there until this is resolved. Don't have to have the whole team, just several people down there. And here's why. He's got a gun. He said he's gonna shoot himself if we go in there. So we're not gonna go in, we're negotiate at some point in time, just be on standby. So, I gave them a call about every hour after that. And then, when we actually got the video camera into the window and we saw him laying there holding the gun like this, right to his chest, he was pointing right at his heart, And I called him back and said, hey, keep several more people there 'cause if you guys hear from us, you're gonna have about 10 or 15 second ETA. We're gonna be right there. So, keep your trauma team pretty close. He's holding the gun up to his chest. And if he fires a gun, it's gonna be a penetrating chest, central chest trauma. We're gonna need a trauma team, big time. So, that's how we communicated.

- [Dr. Wong] That's a great case.

- So, how about any other questions or this is a good time perhaps to open up also for any other people on the webinar here. What experiences have you had if you had something similar to that? Or doesn't have to be necessarily life saving, but what kind of advanced medical care was provided in your arena, somebody you know of? So, share some stories. Bob?

- Thank you, John. It's an eerily similar kind of situation. I was the commanding officer of Naval hospital Camp Lejeune and standing ED watches. And I went on duty at 6:00 PM with an anticipated end of shift at about 7:00 AM. At about 6:15, without any warning, a POV pulled into the ambulance bay and a Marine comes running into the ED. He stabbed himself! He stabbed himself! ED empties out, everybody obviously into the bay. A young Marine had gotten a Dear John letter, reached into his locker, took his bayonet out and impaled himself. They did not attempt to remove the blade. Really, obviously, the thing that saved this kid's life. Got him on a gurney. Camp Lejeune, 1987, was not a trauma center by any stretch of the imagination. We had anesthesia in the house and a general surgeon who wasn't supposed to be in the house, but had been late making rounds. Got him on a gurney and nurses were really good. The surgeon showed up as we were rolling through the doors into the OR. They were pushing the gurney, I was standing on the rails and intubated this young man on the rails moving through the doors. Anesthesia showed up, took the tube from my hand. Surgeon showed up, nobody in space suits, nobody in anything but uniforms. Gloves, masks. He was the surgeon, I was the first assistant. There wasn't anybody else there. Opened him up, pulled the knife out. I literally had my fingers around the blade and compressing. He pulled the blade out, put a couple of stitches and a Teflon pledget on it. We flew him to Greenville and a survival story. Cost him his military career, of course, but he survived it. And so, the answer really is, the instinctive response such as yours, John, gel and ultrasound, and with evidence of cardiac activity, you have really good reason to do something now. And it's that instinctive response. I really don't remember thinking about getting on the gurney and intubating him while we were moving. It's just something that you do. Having had the good fortune to have survived the number of years of emergency medicine and military and police work, I've got lots of stories. Vietnam on a pilot extrication. We were moving and ambushed. Pilot took a round through the face. Low in the face, but bleeding profusely and gagging. He hit the ground and I put a number 10 spinal needle with a over-cath through the cric, pulled the needle back out, put it in alongside the cannula and shoved packing gauze into his mouth just to stop the bleeding and he was able to breathe through those two straws. We took care of the ambush and made the pickup point. But it's the kind of thing that non-emergency medicine people don't understand because they don't develop the reflex. I really believe that what we do as emergency physicians is almost unmatched. I think our trauma surgeons have to make the same kinds of decisions, but they tend to get a little bit more warning. And, in the tactical situation, I know 2019 domestic violence call, I was the second officer arriving. And, as I got there, the first officer was almost surprised. He had separated the male and the female, and there was another male in another room coming out at him. And, one of those cases where my arrival stopped that officer from being ambushed. And I've personally been involved in three situations where officers responding to, again, patrol officers, not SWAT teams, single patrol officers, responding to a DV call, get ambushed by another person in the house or the supposed victim while they're trying to deal with the assailant. And again, you know, my shtick is our tactical teams do wonderful things, but it's our patrol officers who are generally the first ones on the scene. They're the ones that are doing the traffic stops. They're the guys that walk up. And if you come up on the passenger side at night, you see the guy with a sawed off shotgun pointed towards the driver's side window. He just doesn't want to go back to jail and he'll kill you to prevent going back to jail.

- Yep, and don't ever get in his way, you know, and be prepared for the aftermath if you do, you know? So, very good point.

- So, again, I think that as we're changing the name of our section, I think that adding some emphasis to our education of patrol officers, I've mentioned in the past, I've convinced our local county sheriff that it's not the tactical team that needs this stuff. And so, I'm doing a four hour trauma training session, trauma and medicine training session, for the patrol deputies because these are the guys that are 25 miles down the road, alongside the river, and there's nobody to back them up and they have to deal with not anything, but everything. They're the first responders to fire, the first responders to medicals, the first responders to crimes. They're the people who I believe we have to train as best we possibly can. I thank you for the soap box, I'll step down.

- Well, thank you very much, Bob. Sure appreciate those comments. And that situation in Vietnam must have been very challenging, I'm sure, 'cause you're in a hot zone, bullets are flying and you have to make a decision. Is it self preservation, return fire, or is it time for me to trust your buddies to watch your back and do a lifesaving medical procedure. So, that must have been one heck of a stressful choice right there, you know? But that just shows your love for your fellow soldiers there and your commitment to helping to save their lives at your own personal risk. So, that's very admirable and thank you for your comments, appreciate that.

- Thank you, John. I have to tell you, I don't remember consciously making a decision. It just happens. I think that's the emergency medicine reflex and I consider myself to have been extremely blessed repeatedly. But, yeah, yeah, I trusted the guys that I was with.

- Yep. They were definitely blessed to have you with them, that's for sure. You betcha so. Well, thank you very much for that. So, let's have some other comments, anybody else? We've got about about six minutes after eight, we have some time for some more questions or comments. Anybody else like to tell us some of their personal experiences or some stories, some real things that actually happened that other people can learn from? Dr. Christensen, we'd like to hear, go ahead.

- [Dr. Christensen] Can you hear me?

- It's little soft. Lean forward a little bit more and talk loud and we'll be able to hear you, thank you.

- Okay, can you hear me now?

- [John] Yep, loud and clear, go ahead.

- Okay. I was a special forces medical officer for a total of 16 years. My first deployment was out to Utah and I was covering a deployment of an A-team into the Wasatch Mountains, south of Salt Lake City. It was in the middle of the night. I wasn't on the team, I was just back up. One of the 12 men, the captain commanding the team, landed and ran into a, actually, he landed into a high power line. There was an explosion. And his AR16, his M16, which was lashed down over his left shoulder, melted. The medics on the scene stabilized him. And, when I got there, he was alert and talking and just had pain. There were burns around his left shoulder. Maybe some of you can solve this more quickly than I did. We had no transportation and, at that point, he did not seem to be critical. All we had was a Huey, an old UH1. It was not medical, but we pressed him into service and we started to fly them north to Salt Lake City. There were no lights, I had no medical supplies, but I was watching the man closely as we flew north. The group surgeon, a colonel, I was a captain at the time, spoke to us over the radio and said, I want you to take this man to the VA in Salt Lake City. I was a little worried about that, 'cause this was, potentially, a serious case. But he was stable so we continued north flying through the night and I kept checking his pulse and talking with him. And there wasn't much I could do, I only had a flashlight. But what I noticed over a period of time was that he was losing his left wrist radial pulse. His left wrist radial pulse, not all at once, but just slowly over a period of 10 or 15 minutes. And I spoke with him and I said, are you feeling pain? Can you move your arm around? And he really couldn't move the arm much. But he was alert, breathing normally, you know, to sat. So, I changed the destination of the flight to the university hospital in Salt Lake City, Can anybody tell me what was going on? The man landed in a high power line. The current ran through his rifle, melted the rifle, I guess that's what saved his life. He finally landed. Then, as we slowly flying in a UH1H, totally dark in the back with no medical supplies, no real light, except for a pen light I had, he gradually lost his left radial pulse. Any ideas about what was going on? Well, I didn't either, at that point. We got him into the trauma bay at the trauma center at the university hospital. And they said, oh, he's got a circumferential burn around his left shoulder. And in the short period of just 15 or 20 minutes, he had lost that pulse. They did a couple of escharotomy incisions and the pulse came back. He made a complete recovery, although, he decided to leave special forces at that point. End of story.

- That's a great case. If you hadn't been there checking that pulse, who knows that it would've ever been checked, you know, until he woke up the next morning with a blue arm or a blue hand there, you know? So, yeah. So, that's very good fortune for him to have somebody pay attention to him like that. Again, it's just the common, basic stuff. Just checking pulses, reassessment, reassessment on the transportation that casualty backed care that he had provided. That's when you noticed something different and you took action on it and made a difference and he actually kept his arm, you know? Could have been a way different outcome. So, thank you for sharing that case, sir. Appreciate it, Randolph.

- [Bob] John.

- Yes.

- Bob again. Can I go back on that?

- Mm hmm, you bet.

- Dr. Christensen, your case was a training evolution. Wasn't combat, it was in training. I think there's an important consideration there as well. Some of the stories that we heard from Dr. Springer and Dr. Keegan included training evolutions. Just because it's a training evolution doesn't mean it can't go badly very quickly. I was with the 20th SF and we were doing a Hollywood jump into Fort Ripley, Wisconsin. The mission was to train a group of Vermont National Guard soldiers on winter infiltration exercises. I won't go into the whole thing, but the point was, it was supposed to be a Hollywood jump. That's, you're not carrying all your heavy gear. You've got some stuff with you and it's a 800 foot static line release. Supposed to be an extremely safe evolution. And, you know, your tumpline hits the ground, you set up for landing, you land, everything's good. You pack your chute, you walk away. On that particular evolution, because I was the, by rank, senior officer, the team leader, a lieutenant, and I were gonna be the first two out. C-130, except it wasn't 800 feet. The Air Guard pilot had bad weather information, his altimeter was off and we went out the doors at 400 feet into a 30 knot wind. We got two more guys out because we were stacked and rolling. And the jump masters one on each side saw that things weren't the way they were supposed to and hauled the number three people back on both sides. We've got four people who hit the ground. Wasn't snow, it was ice. And getting dragged across ice at 30 knots changes your priorities. I was fortunate my chute blew into a snow fence and didn't jump the snow fence. 'Cause, if it had, I might not be here to tell the story. The lieutenant got tangled in his tumpline. Couldn't roll over, couldn't get his Koch fittings and he burned all the way through his backpack chute, the chute pack, rather, his Dennison right down to skin. He was raw. Third guy, his shoot went into the trees. He had a dislocated shoulder. And, by that time in my life, I always carried a medical kit. And so I had enough morphine to settle down my lieutenant. But we did a shoulder dislocation the old fashioned way with a foot in the armpit and strapped him. And the two of us were trying to get shelters together to protect these two injured. And the plane couldn't land because the cross winds screwed it up. So we spent that day, that night, literally, on the ice, in the trees with improvised shelter, improvised medical care, until the wind died and the plane came in with the rest of the team the next day. Training evolutions. I think that we should be present for training evolutions. I've seen cases where people have gotten hurt with Sim munitions. I do believe that our presence with our equipment and our mindset is just as important in training evolutions as it is in tactical situations. I think we hurt more people in training than we do in tactics. There you go.

- Yeah, that's a great thing, good reminder to everybody. And, statistically, from what I understand, you take a look at all the injuries of SWAT tactical teams, 60% are during training, like you said, majority are there. So if you have a choice between missions versus training, you know, one of them is gonna have a little higher likelihood of an injury there. So, anyway, but thank you for that story. That must have been one heck of a cold night there trying to survive and having a couple of people seriously injured there. But, again, your basic survival skills. I just, yesterday, I started teaching six of our emergency medicine residents and we actually, during that call out, we're actually hanging out, we're waiting for the negotiations to try to talk the suspect out, and two of the residents went and got their kits. I said, hey guys, need med kits or anything? I was very delighted they actually went and they got their kits out. And one of them had, actually, pretty good survival kit. Had a compass, had a little signal mirror, had some fire starting stuff. And they actually impressed me with their fire starting ability, what they knew about it. And you know, probably one of the best things, if you got a striker with sparks going out, what's the best thing to catch on fire? Answer, from my experience, is a cotton ball soaked in Vaseline. You fluff it up. It can be totally soaking wet, your knife is wet and your striker's all wet, soak them in water for 10 days if you want to, fluff up that little cotton ball of Vaseline, one shower of sparks, and you've got a fire. And they actually knew that. Now, to their credit, they still had things to learn, but one of them pulled out their little small signal mirror and, out of the six doctors, how many you think knew how to properly use a signal mirror with a little hole in the middle of it? Who knew how to use that? They had it with them, which is good, they had no idea how to use it. They held up to his eyes like, oh, like you look like this and signal the helicopter up there. It's like, yeah, that's a good start, but that's not it. Anyway, but, yeah, get your gear, be prepared, know what to do. And even during a training evolution, be prepared 'cause you just never know, you know? So, well, thank Bob, appreciate sharing that. Good deal.

- We did okay that night because we rigged shelter using the parachutes and I had WetFire. It's a commercial product. But I had WetFire and a good knife. Managed to get enough wood down. And we had a fire and we had shelter from the parachute halves. And so, it wasn't a terrible experience, certainly better than freezing.

- You lived to tell about it and that's good. So, not too many fingers missing from frostbite. So, that's always good. So, alrighty, we'll open up last minute. Anybody have anything else comments? Thank you very much, gentlemen, for your comments on there and your stories and everything. So, anybody else have anything?

- Actually, really quickly, can I just share, since we're talking about training, share the screen here for a second and see if I can pull something up? Just click here. Click to select, share, there we go. Can y'all see that x-ray?

- [John] Yes. Yes, I can see it. Yep.

- [Brian] That's my left lower extremity whilst training doing CQB and unbeknownst to us, a piece of rebar was buried back in the berm that we were firing against. And I still have a 556 round in my leg. Kind of it managed missed bone, but sometimes even your medical personnel may be the ones who end up actually getting injured during training. So, training can certainly, especially when we're talking about law enforcement training and some of the stuff that we do, can potentially be hazardous.

- Amen, Brian, amen.

- Definitely well said, thank you for sharing that. Appreciate it. So, okay. Dr. Ackerman or Dr. Jessica or Dr. Stewart, Dr. Kelly, anybody else have anything else? Dr. Snell, anything you'd like to share at all?

- Let's see if my audio is working now. You know, the thing with training.

- [John] Go ahead.

- You know, there's a lot of good stuff that we do in training. And you know, you mentioned, John, in your situation, kind of having a plan for how you're gonna handle evacuations. You know, and it's interesting as you get your training more realistic and pushing your training, you know, you wanna find your failures in training, hopefully, without resulting in injuries. And it's funny the question about how much heads up did the trauma team have? You know, I was hearing that and I'm like, yeah, my trauma team, if I call in and tell them our team is out, nobody extra is gonna be down in the trauma bay. That's, you know, our situation and much higher volume. But the interesting thing that we discovered when we've been anticipating using our helicopter or sort of improvised transport options, since often now we don't have an ambulance available, one of the hardest things to actually get done is that phone call in to let the hospital know that you're coming. Either everybody else in the exercise, and in real life, has other stuff to do other than to grab a phone or call in. We tried to have our medic who's going with our casualty dial the phone. And you know what? When you are crammed in the back of a helicopter, an SUV, trying to assess somebody in a really tight space, dialing a phone, or even unlocking these phones now, simply becomes a major challenge. And it's one of those things, you know, we thought that would be the easy part about some of these casualty evacuation drills. Of course, we can dial a phone. Until you make it realistic and then you discover the space, the time, it just doesn't work. And you better come up with a better plan and have it trained in before you have to do it for real.

- That's a great point. Thank you very much, Dr. Ackerman, excellent point. Again, how often do you train, you know, jumbling things, taking care of this, putting the tourniquet on, reassessing and dialing the phone, you know? Is there somebody you can tag for that? And that's a very difficult situation. But as everybody on this call knows, there's just a five or six minute heads up that there's a trauma on the way, makes your emergency department much more functional, much more able to provide effective care immediately upon arrival. So, that phone call is so important. So, great point. So, anyway, it's about 8:24 right now. So, if anybody else has any stories, we can certainly listen to them right now, I'd love to hear them but, if not, let's go ahead and wrap it up there. Anybody else have anything they'd like to add? So, great. Well, I'll take a moment and thank our presenters tonight. Thank you, Dr. Springer, Dr. Bradley, and also Bob and Randolph for their comments and, Jeremy, thank you for your comments there, too. And it's been an honor to join this evening. Hope everybody learned something. And remember, stand tall and stay safe out there. Appreciate you joining in. Best of luck to you and we'll stay in touch, take care.