El Dr. John Schulz III explicará el manejo quirúrgico del paciente quemado en etapa aguda. El Dr. Schulz es cirujano general graduado de la Universidad de Yale con un doctorado en Bioquímica de la Universidad de Harvard. Actualmente es el Director Médico de la División de Quemaduras del departamento de Cirugía del Hospital General de Massachusetts y trabaja como cirujano general en la Unidad de Quemaduras del Hospital Shriners en Boston.
Okay. Um, when I started the totals, uh, una vez mas estamos aqui Erroneous. But a teleconference via the Americans Pull a pass. Estevez. Uh, almost a talisman. Hockey Ruriko. Paciente came on fast arugula. Tenemos committed a doctor. John Charles ls Second for insisting vital'o e s the lsl Cerojano. General Cerojano in a university a Yale Canon Dr. Robin Geochemical, The University of Harvard Theater lamented Director medicalization the Madura, The ultimate superhero Hospital Massachusetts It's a You wanna hinted at a hospital? The Shriners in Boston. The minister Minnesota Linda Guerrero, a Linda guerrilla in Colombia is La Fonda represent Telephoned agenda Tomorrow is almost a miracle. A Juliana Gomez s johanna plastic tambien in Colombia a Fundacion santafe de Bogota just so long as the person asking advantages Connect, production Durant Esta Hello, Confidence. It's dances. Dr. Schultz, thank you so much for being with us on. Yeah, you already. If you are ready, we are ready. All right. Thank you. And thanks everybody for joining us. Um, I'm going to speak about it. Cute care as we do it at Mass. General in the short is like everything else. Clinically, there are plenty of ways to do things. And and this is how we do that. Dr. John Schalit's siento ultrahigh net hospital Massachusetts in Obama's Massimino qualities protocol Ola Mandarin Just money. 100%. 0. Kimmel. So, first of all, we see many outpatients as I'm sure that all of you dio um and the are routine outpatient care is simply too. Do wound care. Apply something antimicrobial, um, to the burn and set up. Follow up with the patient. Don't treat patients with antibiotics in the United States, although that varies around the world and we try to limit our use of narcotics. Aziz, you may know we have an epidemic of narcotic use in this country. Uh, dimension and okay, uh, grandma Element pacientes for consulting Stern. Ambulatory. Oh, it s a case Local Moonen Maria Really Spaces just looks American in a sentence. Ambulatory. So you summon a hard area that while as a military, uh, listen intimate antimicrobial notice an interview because a limited elusive Oh, the superiors, um and we try to manage I would say that we usually manage people with less than a 10% total body surface area burn Azaz outpatients. Unless there's a significant third degree component that needs to go to the operating room right away in general. Santa Monica on ambulatory. Oh, getting in many of the poor siento excepto seat in international. Mathieu Flamini Hanky Ruzicka Um, the next slide just talks a little bit more about outpatients. We don't routinely splint outpatients. We encourage them to move and use everything. Andi, if they are reluctant to do that as they sometimes are, then we try to enroll them in outpatient physical therapy. A use in Canada. Notice a federal assorted cheeses. Specifics Ambulatory oh, implemented stimulant momento the toilets Articulation A e exceptional mente seven alguna difficult. A present, a personal, a physical, a party more in a moment. Um, and if a wound is indeterminant and may need surgery, we will follow it for 12 sometimes even three weeks, depending on the wishes of the patient before if it needs surgery before finally saying way have to go to the operating room in Canada. Uh, you know, Samantha digitalization the a zero here. I loathe last year you look down here, um, for for outpatients we will often operate on them at outpatient basis. One surgery, Then they go home and they follow up with us. If someone has a very deep focal burn, we may excise it and put it on dressing changes or a back, um, for some number of weeks. And for older people, if we possibly can, we will cut the burnout and close the wound rather than trying to graph them. Uh, ambulatory a Sonia Sidhu. He'll lose money, hand inform, ambulatory. Uh, a schism more profound. Uh, just a, uh, back for una a majority. Okay, Ma may notice in. Okay, Uh, a lo mismo lett's a garment that are going to that graphia. And then here are some examples of a typical outpatient burn that we would treat in the clinic. Um, here's another one that we treated as an outpatient. I think the most random pacientes Monaghan formula Toria. One question, Uh, do we owe without patients use what without patients? The A C. Yes way. Do sometimes use it without patients. Yeah, so we are able to do that, and we're lucky to be able to do that. Okay. Okay. All right. So that's our patients. And now for impatience, for the for the severely burned patients, and we'll just take it through how we treat them kind of in their critical care. And then I'll talk a little bit about their surgery. Yeah, um, Lar de los pacientes case and cuenta hospitalist housekeepers for some questions in Los pacientes Katainen Camaro. That's mass expenses you can recreating. Told money. Who rescues Sita? Okay, look, so I'm gonna follow uh, a T l s. I don't know if any of you are familiar with it, but the advanced trauma, life support and of course, ABC or very important. Uh, a e a. So it's important Thio secure an airway. Thio intubate the patient of necessary. And, um, the reasons that we will usually intubate patients are for very large burns where oedema will compromise their airway for hard signs of respiratory distress. Um, and for ah, good history of smoke inhalation with respiratory distress. Um, forsooth, people are like into asean simply Qantas necesario castles in college, considering so no distress. Respiratory open the present day McCollum in Mackay, Madura off the island is a una in elections. Um, and the picture is just a bronchus ka pic picture of the airway with a bunch of sustaining and some obvious mucosal uh, insult la fotografia, a correspondent on the Broncos Copia in a Malaysian prison. Anywhere from you know, uh, crosses the the, uh mhm. And because I don't care on DSO Once you have an airway, the patient has to breathe So obviously they're intubated. They will need to be ventilated with mechanical ventilation on DSO, sometimes depending on the burn. If the burners like the one in the photograph, the patients will require Trump Will s Kurata Mies to release Thean Interior trunk so that they can have chest excursion and ventilate adequately. Segundo Paso now is a pretty interesting 22 hours 40 pesos Carla ventilation He lost break Cuando se unnecessary. Oh, this getting the community stop Servando la fotografia in his area. Really? Saleh says catatonia Jason lateral liberty Callous Trans versus paramedic or 11 Tell ASIO on dfo Finally, on the circulation which is one of the things that most people think about when they think of a big burn injury is through the fluid resuscitation that they will need. Um and we use, uh, calculate initial needs with the Parkland formula, and I put on the slide 2 to 4 ccs per kilogram per percent TBS A in the 1st 24 hours because we're very conscious of, at least in the United States, where we really over resuscitated people for a period of time up until 10 or 15 years ago of not over resuscitating. So we try to give them just enough and not too much by following all the endpoints of resuscitation that air listed in the second point here. Hey, is this paso necessary? Oh, with this Look at those in any mental case. Mozzarella circulation. But I used to actually sell a formula. Parkland used sarin kill a formula, Parklands, the Quattro 4 kg per person. Tahir Super physical Peral Invented What role? Sin embargo, even a star resultado l does Latin desio India is no s Already mention are no the applicant demasiado articles and especially interesting operate contrary o Connell Minimal Not actually an excessive need. A quantity People control the dresses. Control lacked Otto Heart Sang Gina Florina crappy Nina Leverkusen. Delafield convinced Akima consensus really a party more in America before And I always emphasize to residents that this is simply a nen initial calculation that you do to get annoyed idea for the first hour or two. And then you have to follow the endpoints of resuscitation to guide you. It's a question of as important is an anarchist. Una formula with the, uh, controlled starts easy and, uh, okay, present time, but taken taking into a, um um, another thing that we commonly do is we. Although the Parkland formula says, I think to start with Crystal Lloyd in the 1st 24 hours, we very commonly used at least 25% ka Lloyd, right from the start on believe that it makes the resuscitation somewhat smoother. A lot of chaos in this camp in our massive ministries quarto the crystal lawyers, quarter colliders, cinco por ciento aluminum Ana MPs and a controller is tratar evitar Al Qaeda. Gonna so regret your passion in the second point here on the slide is just in the line. I review all of our major burn resuscitation in In the last year, the most fluid that we gave someone was 4.4 point 67 ccs per kilo per percent in 24 hours. Uh, you he said you're a grand reso where, uh, Chema and many patrols. Let's see. Oh, and Another important thing is I mean, burn resuscitation zehr sometimes quite scary. I find them scary and each one is different And one can be tempted to do big changes in the middle when things aren't going right. And we try to resist that impulse and be very measured in whether we increase or decrease fluid based on our implants. He was so l Sonia stuck on the status of the talking, passing this extend semantic mouse in critical and accept, uh, start for $1000. Who's this past off for its like start control number percent permanent? Monto and I'm speaking about intravenous resuscitation. But, um, it turns out that the gut is very good at absorbing fluid at either end on DSO in a Knauss tear environment, Either enter all balanced salt solutions or rectal would probably work. Look, Islamist Fernando and Serapis into elemental, apart. Central, there is a CIA difficult arteries and reduces support rectory, potato and interesting stuff. Fernando Parra, Stimulus electric. Sara una lamentation. Integral. Yes, Orel. Over via rectal. Um, And so once we've got them, we've secured the airway. We've got them breathing, ventilated and were resuscitating them. Um then sometimes We have to do other things, too. Protect end organs like limbs and eyes. And so, um, for major resuscitation is we will usually do serial measurements of inter ocular pressure. Um, and if it gets high, we will do a lateral Can't. Khatemi, Um, for the eyes, Um, for the extremities Will do s Kurata Mies and sometimes for deeply burned in large resuscitation zits necessary to do fast yacht amis, especially in the the lower legs. Um, and I just have I think I have a Siris of photos coming up. Yeah. Uh, attention. Comentario canto laterals When the interim president uh, wah smooth really off that Molla here. Oh, yeah, I think you know elaboration. Intro like you can really sense catatonia, smooth faces, prophylactic comment. Uh, listen, uh, observe body a possibly a yellow paint off of argument video really isn't a revolution. Last year a video? A grand success. You understand? Caring, Granted aluminum. I have a question. How frequently on the creation High intraocular pressure, How frequent is defined. How how frequent. You in the larger can totally, um usually we do lateral canton amis In people that have the distribution burn, you might expect, which is like up to here. They have deep facial burns and large burns. So the combination of, uh, noncompliant s car on the face and around the orbits and large resuscitation requires that but occasionally ah, large burn without facial burn injuries will have elevated pressure. Eso I would say we're doing them. We admit 350 patients a year, and we probably do it three or four times. Ah, year. Uh, a no liberalism. Uh, the second Massimino. So the total day, those interesting progresses. Patricia Sequent aggressors, assign owners. Those trees align. Okay, okay, so this is just This was a two year old that came in with circumferential burns. And it's just a little video of how we do s keratotomy. No sistema strangle manera Let's catatonia and non Criscito does and use their mhm, you know, like about collapsing completely. But it's mhm. Usually we never have bleeding in any surgery, but this time we did in normal mental 10 in Muchas angry tarantella zero here. But in a separate statement into elementary Yes, look, a Palestinian state and local currency limit out a compression. Okay, here's another picture of a guy that had a pretty significant circumferential hand and forearm. Uh, burn. And so we did that scrod Amis. And I just put this in here. Thio know that we're listening to the Paul, uh, most correspondent. A profound. That is circular smooth catatonia, Santo animal del Carpio Koulamallah. So, in my opinion, that was one of my junior partners. In my opinion, we can use cap refill somewhere if we have normal skin on the ends of the fingers to tell whether we've done a good job. Mhm. Can you repeat that, please? I said we were using the Doppler there to measure. Uh, but you could measure cap refill on something that's not burned. Uh, doesn't do this. Listen, it's a castle. Look. Utilities a cel para terminar just a little extra and then another. Just another example What drew him? I have a new partner that loves to film thing. Mhm. You know, no companion. Last week fill in Canton Surreal Doppler. I almost committed, uh, automation content, Doctor. Sorry. Toil of this and those Esperon amis on the hand were typical and that they were radial and ulnar in a couple of dorsal s Kurata Mies placed in a position that you could also do intrinsic fascia, autumn ease. And if you needed Thio Awesome. Let's get outta me up almost essawi radial coital l door salesman I e Cicero Cave in Grand assistance on the condo I grant this voluminous standing in the same passage, Tony anywhere in principles. And here's ah few pictures of lateral can thought of me and this is just a a photo of measuring the pressure in the eye. Sistema Trajano Photography are and understand media Angela present on the law and then this is not very clear, I don't think, but this is how I typically do. They can thought of me This simply use the back of a forceps to protect the I. It may not project well, but there's an ads and forceps right there. And these air Metzenbaum scissors cutting the lateral cancel ligament A photo, Clara. Most random scale of most important is protected. Local are Hello, Cinchona protector. Local uh, Moscona, uh, section yes, corcula. And somewhere there's a picture on there we are, but pressure released, we're all set. Why? No, I use almost Randall apart elegant Otomi And then I just put in one more. This is not an electrical injury. It was, uh, kind of a second degree injury. But the patient was intoxicated and burned his arm, fell on it and then passed out for a few hours. It's the paciente a electrica a circular federal paciente starting talks CCR. So he presented with kind of not a very bad burn, but he had a dorsal compartment syndrome. Yeah, a circular isn't any income from a compact. And so there you see the fashion partially open there in the muscle, bulging out. Yeah. Observe our kamala possessed a parcel meant most current pizza, etcetera, they insist on and then the door. So a compartment totally released mismo compartment or completamente Live it up. And then this is improvised distraction device to try to pull the skin together over several days. Many of you might have used something like this. No e a thing. This place e a e o k e again my youngest partner and his new old ideas. It's a plastic Mhm. What do you do? Tithe The ties. What they're doing is they're doing dressing changes in tightening yes, material material. It's plastic. Yes, it's vessel loops. Elastic? Yeah, I and the way that I would treat this is I would probably vac it or leave it on dressing changes and then close. I think I could probably close this after a while without a graph. Like a list are back. Esperar a que no yellow They made a just the company. Uh, and then this was an electrical injury Where, um, we have done a carpal ligament release and done fascia. Autumn ease of the hand in the forearm. Soon a typical electric CIA observing lotto necrosis the cardinal, uh, you in elevators and dealt another car with the total compartment qualities. Thomas Randel Doors. Yeah, eso. Now we're gonna leave the photos for a minute and go just system by system. Kind of how I think about, um, critically or burn patients. Our our mission, our alcohol Systemic. All you know, Peru? No. Um, I'm sorry. Um, so we most commonly is morphine and midazolam. Um, and fentanyl, sometimes hydromorphone sometimes. Um, but morphine and midazolam are the kind of our main stays. Okay, a morphine amid a salon. Pedro Martinez, Zambian National Mental Antony possibly acutely. We might be more inclined to use fentanyl on the 1st 48 hours because it has somewhat less hemo dynamic effect. You know, algunos pacientes getting in the factors more dynamic. Parochialism, ourself. Antonina premier has been quite record entire chores, and we try to avoid the use of propofol acutely, because it has significant hemo dynamic consequences. A propofol for less effective, less consequences dynamic keep in. So it can also in an inexperienced hands drive, um, over resuscitation because people are trying to compensate for the hypertension caused by the propofol. A experiment task, uh, roared s or rescue Sita for 4000 impotency on in transistor A. The companies are like petitions with Minister Malik ul. We use, uh, Dex Meta Tom. A date quite a bit in Children. Um, not so much. And adults. I just In my experience, it it's doesn't work that well. And older people, uh, Santa Me Index met Dex meto marina Mass. Aminu's, uh, does not happen being, uh, scallops and mussels with me. And we will sometimes use clonidine. Can be undergoing asbestos. Suzanne Giannina. Um, from a pulmonary standpoint, um, we use a pressure assisted volume control. Um, in the sicker patients, there's a comparison, uh, on a this positive para terminal controlar el oppression they will you make. But I think a lot of ventilatory muds or compatible with good care. And it depends on how wake your patient is and what you're intensive iStar comfortable with. Pero Dr Prescott lost this positive. Who saw Para monitor Laurenti Last person involvement Effective the Mendez compensation talent. Insidious Com O K Positive catalyst Consent Paciente tambien we dio small bronco a mini Branca Avila LaBonge on admission just to find out if there's some kind of dominant flora, um, in in the airways A e So a dominant kissing booth, then we will, Um if there is, we will use that information to help guide empirical antibiotics when the patient gets sick, like we know they will. Yes, uh, administration, the TV, because empirical personality see, complete commits a cone, press con borrow effects. Yours. Okay, so I must say, representative passengers toe came out. See a musical Bella Flora, Katie and compassion is just a empirical. And we will do a diagnostic bronchoscopy often if there's no If the history is totally incompatible with a inhalation injury, I may not look, but usually we will look, um to see if there's any evidence of carbonaceous material or evidence that there were toxic gasses in the airway. Mucosal injury, predetermine Arcia material Carbon ASIO, CIA. It has a toxic cousin lobby area. A menos que moving compatibility story can keep a calcium loss. And that doesn't help us so much. I mean, are our therapy are critical? Care is very impure IQ. So the bronchoscopy doesn't really do you guide us in therapy? Um, but it does give us information about what we might expect as the days progress. A scary movie information bronchoscopes, uh, more revolutionary team. Um, we're pretty aggressive about weaning the ventilator and trying to get people off of the ventilator. And so I'd say, over the last 15 years, we do probably fewer tracheostomy knees than we used to, because way more often wean and X debate people with larger burns. But but still, we have a fair number of patients that get a tracheostomy, and we will usually wait 10 to 14 days. Just some geography, straight interested person. L've until our trapped on the lawn, especially in a post on carrots and your mother's passing this camp bacteria tracheostomy uh four months I pass in this case, uh, councilor tracheostomy looking religious release and quantum passing video the serious into Uh um yeah, if if a patient is persistently taqa Kartik despite being apparently by all other measures adequately fluid resuscitated, we will give them some beta blockade. Still passing purposes. The Kentucky car, The cartoon aqua. Uh, reanimation Colicchio. Look, locate just realism is a minister passing Vettel locales and we use pressers assassinated Thio maintain a mean arterial blood pressure between probably 55 60. Uh, go ahead. Sorry, sorry. Sorry. Paramount Yona prison arterial media. Interesting. Quincy's increases in. And if we think there's a cardiac issue going on, we will do an echocardiogram. We don't commonly measurer cardiac output. Hey, just see stanza speech. And can you tell us your name? Your cardio? It's really someone echocardiogram, but a terminal people. All right, um, we start feeding early and we use a non anabolic steroid just initially in lamentation. The formative prana, um and we don't use tp are peremptorily nutrition very often, but we will use it if someone's going back and forth to the operating room a lot to try toe and and they start out malnourished to try to make up for all the time that we're not feeding them nose and more frequent mental nutrition. Parenting a passing interest Based on your opinion, Constant meant a kid off. This is a constant men, and there's always a running battle with our NSC's Ecologist. We like to feed the patient. If they have a post pile or a tube, they could be fed right up to the time of the surgery. And even if they have a gastric tube in a controlled airway and they're gonna stay supine, we wanna feed them right up till before the operating room. And and often we can. Okay, simple thesis. The interest condos Anesthesiologist Booth with low, low aunties Must possibly Where did you hear it? A solicitor here. Inmediatamente predicates. Allessio. Here It's a soon as 600 president. Today's question. Que se case opinion, clothes and poor communities. This is no supporter. Initial documentation campaign promise you he onda. We use wound healing, indirect Kalorama tree and serial waits to assess nutrition. We do measure pre out human and and other things as well, but the real money is are they healing? Are they maintaining their lean body weight, which they don't. But we wanted to keep them from losing too much. And are we giving them enough calories? Entry la's Lamento utilization para poder terminal position system for my purposes. That calorie Metreon Director, uh, sister Ecuadoreans seeking your assistance and and, uh, pesto. Just don't be impressed, Quinn. So this is a booming A or trust examining pretty parliament. Sns Trotsky less accouterments. You're not kill. Is the term inertial passing test again? And Lopez Oh! Oh, no. Stop At the end of the last three, Assistant Santander Formica. Um, So, in terms of of the g U system, I mean way want their kidneys toe work. We want them to be adequately resuscitated. Uh, way will not chase urine output endlessly or chase chase low urine output endlessly with fluid if other resuscitation in points look okay, um and we have readily available um um Reno Replacement therapy, if necessary. Way criticism pronto star system monitoring, audio kill passing thing. Gonna call function aumento unions a just Oh, you mean, uh, Perry. Just no kidding. Mr. Paparazzi Lotteries is therefore MMA. He limited. Okay, I just a mental patient ascended Catherine aereo. You know, A during his form A, uh yeah, um, we like to maintain their hemoglobin above seven. Um, if they're really sick, I'm I m pressed for higher than that. Um, as you many of you are all of, you know, burn surgery can be quite bloody. Uh, we, uh we try to reduce blood loss by using very dilute happen Efforts sailing, crisis injection, subcutaneous lee. Um, and we use it topically. We use tourniquet. It's we use thrombin onda. We use something called quick clot. I don't know if it's available, um, outside the United States, but it's basically got impregnated with Kaylin, um, which gives an active purpose for plot. Deport. You look, a kidding is for the question that in the global arena with the, uh, Chris, I commenced in our kingdom, lamented tall a particular Rica's movies, Angry ente the entrances. Moskin in percent is extensive and came out with the controller dentro uh, fallacy to hear e a second most. Atticus. Yeah. Poor administration soup. Dammika the fina fina in a hotel or topic. Um, and technical solution Selena solution. Pininfarina isn't complicated from Vienna in Messina, So paycheck and a lot of music. Uh huh. Okay. Former rapidamente wow. Locally pregnant legacy Vatican Sevilla area. We got, uh and we use topical antimicrobials. Um, mostly we use silver based ones. Um, just because of their broad spectrum and they kill fungus is Well, um, we still use a dilute silver nitrate solution mass general and striders. We also use math, and I'd in Bassett tracing. And these air, I think the topical antimicrobial of choice is very country specific. That's what we do here. Oh. Mm hmm. The interest in Monaco topical the area. Suzanne. Antibiotic ALS present microbial, you Spectra Kamala Super Senior Platter, Crystal locations. Massoud, listen. You know, Jonas Akesson is a Zen represent on the map in all of our dracena. Okay, so that's a little bit about a system based approach to the patient. And now I'm going to talk a little bit about surgery and then show you some examples of some things that we've done recently. Uh, allow Massimino the okay, let's talk a paciente Montaner Bol paciente en este momento. Uh, yeah, Strict until a particle Ruzicka um s o when a patient comes in with a large burn injury because we have readily available Allah graft. We prefer to have all the s car off within 4 to 7 days and pass sentence. Pakistan. Extensive intake. Mouse NGOs, Bustani A cell intervention Cairo, Rica. Molten granite this morning. The Alan Curtis e muscles by so many since 30 years a Stanton Endo 100 out lapel Mottola's cara um, in our favorite instruments are made of steel eso the Watson blade and it has many names. I call it the Watson the Julian knife. Um, there are people that use derma tomes to excise. I usually don't only because I think the blade skedaddle faster and you have to keep changing them. And I like that handheld knifes better. Morales is, uh, family manuals. And Watson will brilliant preparing the second with when autocracy Johannes preparing their motto. Lose their motto. Most Electric Co's This is a frequent A facility, uh, my wife. And because of the reconstructive problems, um, that air caused by fashionable excisions and grafting, we try not to do fashionable excisions if we can possibly avoid it. For a re token political reconstruction post Terry or Cuando se les issue NASA pasa el trata de Vittorio Catholic area exceptional mental and gigolo A set. Okay, so you're a condo? I say Knew it. Andi, Here's an example of ah, back that we excise tangentially. And then we place, um it looks to me like 1.5 toe one meshed Allah Graft on it. Yes, that's unprecedented. Mostly mandalas Correspondent Paul del Paciente on the flickering Ali herto in Machado's pronto pronto. You know, sink. Yeah. Now, here's, um, um poor lady that live a cigarette after I think she was Oh, and she was using hairspray at the same time. Um, that didn't work out well for her, but this is just to illustrate that on the face, um, acutely, we would use unmasked graphs. Um, and this is the day of her operation. And this is one week later because Casa esta present Andorra on a CNN The parent, Ana Kamala Kara looking so smooth. Pharmacy Montana is a proto primarily positive application. The courtesan Latina suppressed during the corpora. Thank you can see her ear and says she needed some more work, but she was off to a good start with these. And this is just This is an example. This It's hard to tell, but This is buttocks and back of a child grafted with 2 to 1 meshed autograph a herto in my house. He will make you know eso for the big burns. We try to get the Escarra off fast. Um, grab them with Allah. Graft usually. And then do stage two. Replacement of the Al A graph with autograph. E o E o A studio. Uh huh. We don't always follow this rule, but I liked it. Keep it no more than 20 or 25% total body surface area at a time to keep the blood loss less than a leader in the operating time. Less than two hours, if possible. And the other thing is, you've got to communicate with anesthesiologists. Why you're doing this Cuando no cm president Loathe their said noona. And remember Cemento sa Lokichokio controlled Beta Adventis Inc interest Candelaria, Kamala can Ayanna Perdita Majora only trace angry. Uh, first question is important is communication Channel logo. We saw the tonal pacientes Casson mass critical that revolution capacities continue to suspend the lesson plan. Um, and just to show you the oh, there, there's my favorite instruments. Uh huh. What's in it? Julian? Yeah, on Do show you that I don't always follow my own rules. Um, about blood loss. I took these pictures. This was a patient with a 60% total body surface area burn and a burned scalp. And we kept dressing the scalp and dressing it and dressing it. And finally, we said, we have to graft it. But by that point, his scalp it for a long time was very inflamed. And grafting the scalp could be a very bloody business. Uh, siento no Rondo Cuomo Cingrani liquid Europe a calm and, uh, wow. So many people. Okay, we were ready for him. We had a nice chest full of blood in the room. I'm sorry. I'm sorry. Can you repeat that? I said we were ready for him. We had an ice chest full of blood in the room despite a suspect. Thank you. Yeah, E uh huh. Um, So here. I just said what are custom is in terms of meshing, um, the graphs we won't mesh graphs on the face or the genitals. And I used to include hands on that. But now I've started using 1 to 1 must graphs on the hands and functionally It's pretty much the same, um, as a sheikh craft, and it's more forgiving. So we do that on risk. Hands, feet and ankles. And then 2 to 1 on the trunk and extremities. And then 321 for the really large burns mhm barrel a party Ellen Machado Machado or suppressed Okpara carry genitalia. Noted Lisa in my house. Uh oh, no, no, no, No longer sovereign aunties and manos me and Monica Hospital took the step, you know, affected espresso solutions of the finest and most extensive U R s PS two videos in the way. But trunk appearance e e Brazos Totally Santoso No, in Grand Cayman, also on a trunk open ISI process. So now, um, I'm gonna show a couple of things that, uh, that I think are exciting. And some of the world knows about these things and some of the world doesn't. The first one is enzymatic excision. People are finally Sarvas referential. Uh, algunos prosimian tusk presented in the booth. Notre Snow is a referee Locadia Comedians sec on enzymatic. This is a product that is available in Israel and Europe. Ondas being trialed in the United States. I don't know about South America Whether it's available in some countries they are using in Argentina. On Chile, Uh, when examination and a k tok the Raelian Europa, uh, in Latin America, lose, uh, mention and focus on the Poconos Mental run Tempus outside in Argentina and Chile. So the enzyme is bro Malene, uh, from pineapple. And the product in the United State is called Next. So Brid s l a Visa and international, uh, soothe. And so here is a burn that most of us would whip off to the operating room and excise that nasty looking third degree. It looks like a third degree burn. There s Thomas Rondonia, Madura keeping Atala. Perrin says their data growl. Um, but instead, as part of the tri ALS, we mix up our enzyme. Yeah, it's the most common mescal line. See much. Okay, So you think you know this is for surgeons that like to cook? Oh, come on way have our enzyme. We have our burn on the back of the leg and now way Put it on. Oh, malaka laka. Mr is in part loc Afghanistan. Venus Costa Pakula casino and the surrounding skin is protected by a Vaseline like substance. Uh, Selena, once the enzyme is on you wrap it with plastic and wait four hours. You know, uh, application a condom, plastic parent cuadra and then come back. And the enzyme has has, um, taken away what's dead and left. What's alive? Uh, important. Essential Iraqi escape. A zealous Quatrano. Most Randall aspecto Lomas important escape with Okay, I'm uh huh. Okay. Yeah, like a bar. Carla Action Desta Encima Sandra, then. So this patient then was okay. What are the indications to use that? Clean up fine. In what patients? You use it? Well, it's but we are using it so you can use it in, um kind of deeper. Second degree and third degree burns for us. It's part of a study. Eso were Are We are part of the safety study for the product in the United States s. Does it hurt? Does it hurt because you talked? Oh, yes, it does hurt. Sorry, it hurts. Yes, it hurts. So we have used We used, um, Benzo days opinion, and, um, a no p oId. And sometimes we will use ketamine for these people while this is going on. And in one patient we did femoral nerve block or it the West African Tando. See, uh, a cheesy. And so I said, Just stand over in Syria. Subpoenas? Yeah. I mean, don't stop. So that was that was a great question. You thank you. And there you can see the wound bed close up. Here's a Here's another patient. Um, and I'm gonna take you through her operation and her results. Uh, yeah. This is after we had taken the enzyme off and washed her leg. It's a moment we are reading all lie and see my local while and here she is in the operating room. This is a video, but it doesn't work. I've tried it again and again. Um, that and she's being the wound is simply being scrubbed with, like, kitchens. Scrubbers. Mhm. Okay, okay. A video A on a high casino. And here is after they finished scrubbing. And the bleeding is pretty much stopped. Yeah, a very tho is, uh oh, yeah, Sandra is minimum and hear her skin grass and bring herto And here is five days later. So in Korea, this place and here's two months later you those message master. So I think that there are some Very good. Yeah, There. I think there are sometimes in the future that steel will be replaced by pineapple enzymes. Yeah. Second to square in place. Airport. Uh, like Seema the devil Opinion e will say it's not perfect. Okay, um then then the next thing I wanted to show you, we sometimes in desperately large burns, um, or very sick patients. We will use, um cultured, autologous carotene. A site. Brats. Hello, Democrats. Uh, solamente en casos extremo this desperado more extensive QandA e mask Italy's R s. But he's a mentor with a Latino Cities s O. This is a young man who was sustained a 95% burned from a Molotov cocktail. Hey, has been repeatedly Allah grafted and And in the photos, you can appreciate that there is one point, like 1.5 to 1 or 2 to 1 meshed alot Durmus in his wounds a a me Cassie Scerbo also hey, has six toe one meshed skin harvested from his scrotum in his super pubic area. Uh huh, Yes. Is that you don't care se my grand the only say, uh, carry on anti HLA party the movies, escrow and on top of that. We place Vaseline Gon's back carotene A site sheets is, uh, e una a la dermis encima out her toes, and my house is already yoga Compass. Alina, uh, Montecito e eso the way. Take a biopsy. A company expands cultures the carotene insights expands it into sheets 6 to 8 cell layers, thick aan den. We put it on the wounds and wait for a week. Uh, e waste a Tina Latinas last, um, on a subservient rest stops, and then we take off the Vaseline and I'm going to show you a Siris of photos. And if you haven't had experience with this usually people are dismayed when they take off the Vaseline gauze backing, but the result is usually better than it looks if you wait for a while. Mhm Obama star. Uh, give me a paciente, I suppose. Several capitalization, it is second rest of Dauphin. Alice McCord blocks away. And, um, here's an example of the where the cells were placed only on the Ala Durmus with none of the widely meshed autograph. But it's a process of our chemical Carlos cappuccino Zito. So I love the enemies in Also, they lost out of here. Um, mawr The same. Um, And what I can tell you is that that 95% burn young men went home. Um, so he made it, and there's another photo of him. Another time we were using Selves. Oh, that was That's the room temperature e Put that up to evoke e uh, Thomas Randel at Imperatore Croquettes. Arevalo Strength and also the most. And we've been in calculus on don't be Brianna Patoka Sola temporal turismo yellow wire. You know Thomas Rondo and memo sent various Mementos. Kiriko um this is ah, baby, um that we is a patient here. Um, 85% burn. Yes, Uh, very. Here is how the carotene asides air delivered in culture medium uh, on top of this, Vaseline goes back. Yes. S l a presentation. Kamal s and beyond all logic. I used the skeleton aceto una casa salina. Here is one of my partners, Doctor, one of my partners, Dr Sheridan, Putting, um, putting a seat of this on the on the child. Next stop Sarandos Most applicant constant companion Supplicant Alaska. Latinos, It. So there's a position, uh, more expense in I I wanted I I should have taken a picture of him. He's closed now. The baby is closed. Um, his, um He's still here because he's still winning from the ventilator, but he doesn't have any more open wounds. He has been here since February. I use the most random s tallest in 100% you know, most important, stat. Total meant you start victorious. Taken ventilation. This guy diverted eso Finally, The last thing, Um, there's a product developed by Fiona Wood in Australia called Ri Sol. Yes, the social product. Okay, police Alatorre, Fiona and Australia. And And it was trialed in the United States and recently approved here on day, we had a patient with a quite a large burn and a lot of second degree burns. Um, and just with his age and the extent of burn, um, hey, didn't have a lot of good donor sites, the needed coverage, So we use resell. Yes, l investigation. Centrally. Sando corn in Brazil s President Hassan Tambien association son out of cultivos auto with the Latino Zito's Yeah, most random Casella tomorrow herto and so this This is the donor site marked off into, um uh two or three centimeter squares or rectangles s a r s Thomas Randel Ellaria Ananta on the tomato Lost out in here to steal a DVD in In curricula the centimeters quite house each of the pieces of a split thickness crab or split thickness skin our trips in ized eso They're putting a warm trips in bath and then the epidermis is dissociated from the Durmus and then the the as much of it Aziz much of the basil layers scraped off as possible and put in a solution and then sprayed on the patient Uh, e a and s a e a the membrane of a cell. Subliminal austerity No Zito Caloocan noona solution a solution. Selena Yamuna had invested replica Ah manera play and way used the resell and the 6 to 1 very widely meshed autograph on this patient. Um, they loathe content on the Internet. Yeah, they say, Yeah, we're on the application in Brazil, and, um, after you spray on yourselves, you wrap it in something else that looks like plastic. That kind of breathes And it, um, vapor. And I think fluid can transpire through this covering on. Do you take that off after a week? or so Yes, Priscilla the elemental current and being common plastic. Esteban Massimino A more often. Now, now that's kinda sorta like in Colombia low tuvimos you see Muslim party casos Hillary town off. No phantom promoted or is four k in the process? L English way for creating units on the on the term in Iraq in public and anatomist uh, ski Latinos Ito's He knows Thomaston Seguros can and bargain a replica Kevin MBA Selena in Osaka Sokolow Candle Amini Kansas City in Estill que Hello, cow and spray with around the Sopranos Latino situation Recetas para nosotros No satisfactory. Yeah, you were not going to translate you. Please. I had some experience, Waisale here Colombia. But we didn't have, like soft because with this type of application with the spray thing, we're not sure that the cells are We're gonna be the cells if they're gonna be placed where we want them to be. It's more secure with catina cycle she than with that with this pray Tarantino sites because we were not sure if they reached the place that we wanted them to be. And we didn't get results in Asians Way were worried about that This is the first time we used result, and, um, we were skeptical, and it ended up actually working fairly well. Um, the patient was admitted the beginning of Mark. So in his home now, um, and I think that we did actually get some distribution. No cells. But I agree I feel more secure with the kind that comes in direct angle, and I can lay it on. I believe that the Indus a k e skeptical Parliament no mention and a e mhm eso in march. So, yes, this is just a circus, like, let you know. So that's it. We're almost done. Um, in terms of fixing the grass, we use mostly skin stables, Um, for absorbable suitors. Um, there are a number of people in the US that use mostly fiber and blue of one kind or another to fix their graphs. And I have done that in the past. Um, I don't feel strongly enough about it to argue for the particular type that I think works at Mass. General. So I use Staples and, um, then post operatively. We use a lot of splints in our patients. There followed. Patients were following pretty intensively by physical and occupational therapy way. Leave the primary dressing on for five days. Um, although that's variable in the United States and we most we often don't mobilize patients for five days, although that is a long time, and there are many people that mobilize them much faster. Well, the Tories topography hard lesson here to utilities and all those guys just to observe you. Playoff arena Pagan farina purposes a Fiorina Hamas. Those catches it could respect proposal territorio reason After the post for General El Proposito primary. Okay, handle the 40 years you're at the soc employees. A surprising knows a movie. Lisa Dr. Repair Post case the president Problem gobble algunas personas purposes young use. Uh, okay, you know what? Let's get prepared in the movies. Is your plan a fade away To see the person Korea see, movies are like Samia will attack ifwe effort way. Want them out of bed a soon as possible eso way. Start trying to get him out of the But sometimes well, usually they have to be off the ventilator. But not always we might get. We will get them out of bed into a chair even while they're on a ventilator for low calcium here in San Carlos Telecom alot and possibly assist a convent Louisiana lazy and break estate for San Carlos Telecom A contestant co stars Coast Fundamental as you see on a seizure, Juan Carlos, mobilize our Ross Perot Paula federalization. Uh, and that is all I have for you today. So I would say questions. Yes, Doctor, I have a question. How do you treat How do you treat the con Drive this trade. What? They contrived us the ear. A z injury? Well, acutely. We will cut off whatever stud and then try to close it and then reconstructive the post A regular flap. But, I mean, basically, we try to cut off what's dead and get get split. Taking a skin grafts on and then reconstruct later. Do you use a drain, or do you leave a drain in the ear if it's too swollen to swollen? Um, so under what condition do you mean? You mean you mean way, Will? Yes, we will sometimes stent the external auditory Miatas. Okay. Okay. So CNN Preguntas brutally Salem Anita came on a very in a party inferior Jesus Pontius Alaa Labonte Youssifiyah second Kara Monta. And it's the moment of tango. Uh, Marta, our villa Pachon. Marta Gorilla wants toe Has a question for you, Dr Scholl. So I am gonna give her some audio and video so she can ask. Okay, Marta, That's why Marta. I can see her name on my screen. Mark Preston E national una Pregunta element Angela Mono for McKay. Just taking Clinton Preguntas put forward Marta politic Martin, Stay. Okay, Marta? Yeah. Oh, okay. E, get my stuff. You know, the prisons The 19 of Mickey Mouse's a a Uh huh. Joe Barbara Dark in a party. Reanimation Israel electrolytic a C c Emma Eliza Intolerance pacientes tres quarters The solution Selena. He cuarto women and told us passionately or Solis grandes came out. Yeah, yeah, no off. Hola, cola. It's called Qala in all the patients, when you're good for resuscitation or use it was the but very major bomb patients. Yes. Yeah. No, no, no tithe. Uh, Dr John? Yes? Can you hear me? I can hear you. Don't When you leaving School breaking up? No, Ken said Linda, Don't let your hair grow phone. Nobody started when you when you you you e Yeah, when you think the fluid resuscitation resuscitation you use, it reports off Crystal Lloyds and the one port off Colloids in all the patients or just the major burn patients. Um, great question. Um, in most of the most of the large burns, So most of the burns requiring resuscitation. So I would say, But I mean, anywhere from 20 to 40% can require will probably require resuscitation. I would say all the patients over 40% and somebody with a 30% burn the resuscitation. Often it is not so large. Um, that we would do that and they're not gonna have the same kind of stormy course, But eso so, Yeah, the major Burns s a request for a look. Pretty Savalas Crystal this part Crystal this coming out. Kanaan cuarto the album in alkaloid this Paratore facilities second. Okay. Parallel passage. Since I've been taking mouth through elementary parents email Quaranta pop scene. Gracias. Okay, there is another question here. Hair mania. Stasi harmony. Contreras alone off. Which is it is yes, nothing. How long will play your cousin is child before you different. So viola connection Nothing. No, I you stand, I go not a Pregunta. Okay? Why? No publicity. It's a stall. Police Efficacy! Ueno It's excellent. Thank you so much. It was a great conference. Thank you so much. Thank you. Thanks everybody for coming. It was great to see you guys. Oh, there is a there is someone saying something, you know? No, I just can't. Congratulations. Yes, they said from Dominican Republic. They say that Congratulations on that. They work very similar to the way that you are doing it in Shriners. Thank you so much. And excellent conference. Thank you. So yes. Yes. Everybody's saying thank you so much. Congratulations. Excellent. So thank you, Dr Schultz. Thank you so much. Thank you, guys. Thanks everybody for coming. Thank you. Talking e bythe so.