1 00:00:00,420 --> 00:00:18,100 I sort of. It's a pleasure to introduce three speakers today, Alex Novak, consultant in emergency medicine and ambulatory care here. 2 00:00:18,100 --> 00:00:23,560 Lois Brent, associate director of clinical studies and consultant in emergency medicine. 3 00:00:23,560 --> 00:00:27,010 And Phil Homebrewers, consultant in Emergency Medicine. 4 00:00:27,010 --> 00:00:33,610 So I'll hand over to them. Thanks very much. Thanks very much. 5 00:00:33,610 --> 00:00:39,280 I'm Alex Novak. The free in here and we're all consultants here in a new age. 6 00:00:39,280 --> 00:00:44,170 Quite a few familiar faces here actually already, 7 00:00:44,170 --> 00:00:49,660 and we're in the process of going through something of a renaissance at the moment in developing our 8 00:00:49,660 --> 00:00:56,950 academic and also innovative and a portfolio of projects and some of the things that have come up, 9 00:00:56,950 --> 00:01:02,170 particularly around imaging in the emergency department, relationship with radiology and clinical pathways. 10 00:01:02,170 --> 00:01:04,840 And this is what we really want to talk to you about today. 11 00:01:04,840 --> 00:01:10,000 So this is going to be I mean, I'll give you a bit of background and context and that sort of flesh out some of the ideas. 12 00:01:10,000 --> 00:01:15,190 And then really what this is is a brief portfolio of four distinct projects. 13 00:01:15,190 --> 00:01:19,090 Both have similar themes running through them and just reflect some of the ways in 14 00:01:19,090 --> 00:01:25,210 which we're trying to develop our approach to imaging in the acute care pathways. 15 00:01:25,210 --> 00:01:27,340 Phil, I will hand over to fairly shortly, 16 00:01:27,340 --> 00:01:33,500 and he takes some questions that he has to go and stem the tide at the front door in a minute, so I would try and get through. 17 00:01:33,500 --> 00:01:41,380 So really, the context of this is that the the economics of acute health care is this country's rapid flux at the moment, 18 00:01:41,380 --> 00:01:45,430 and I think this is no surprise to anybody in the room. 19 00:01:45,430 --> 00:01:53,020 There's tremendous pressure on the front door services, which is steadily rising at sort of 10 15 percent increase year on year in attendances. 20 00:01:53,020 --> 00:01:59,080 And as everyone knows, the hospital is just fit to burst. We've got no bed space and that creates a tremendous pressure. 21 00:01:59,080 --> 00:02:06,990 And it puts, particularly on the clinical staff time and attention of clinicians is just become this this incredibly precious resource. 22 00:02:06,990 --> 00:02:13,420 And equally, the one which is going on sort of sort of key diagnostic tests of imaging. 23 00:02:13,420 --> 00:02:21,970 This one of our key resources, the cost a trimming down, becoming more accessible, generally becoming cheaper, technologies becoming cheaper. 24 00:02:21,970 --> 00:02:25,540 And this is leading to a big shift in cost benefit towards pushing some of these tests, 25 00:02:25,540 --> 00:02:34,150 which are previously fairly ringfenced into the specialities and into inpatient care by actually pushing closer to the front door. 26 00:02:34,150 --> 00:02:41,020 One of the movements that you guys may be aware of those same day emergency care and this is a big drive by NHS England at the moment, 27 00:02:41,020 --> 00:02:45,940 covering every speciality in pretty much every speciality in the hospital responding to this at the moment. 28 00:02:45,940 --> 00:02:52,180 And this is the only thing, perhaps, that there is a tangible health economic benefit in getting people through the 29 00:02:52,180 --> 00:02:56,380 diagnostic pathway and the care pathway quickly so within a 24 hour period. 30 00:02:56,380 --> 00:03:02,620 And that, of course, is no news to any doctors. We discharge about 78 percent of our patients anyway. 31 00:03:02,620 --> 00:03:07,450 But the idea of perhaps tying some of the longer clear care pathways together and trying to see if we can get 32 00:03:07,450 --> 00:03:13,450 people through the whole process and get them physically out of the hospital in that time and all this as well, 33 00:03:13,450 --> 00:03:20,170 is that a backdrop of technological change? The machine learning is as have big implications for imaging. 34 00:03:20,170 --> 00:03:25,090 We have a big centre here which we'll talk about in a second in Sydney and this 35 00:03:25,090 --> 00:03:29,110 this really sort of extends the potential for the capabilities of imaging into new 36 00:03:29,110 --> 00:03:36,240 diagnostic domains and also the capabilities of auto reporting or so automated reporting 37 00:03:36,240 --> 00:03:41,560 in the way of processing large volumes of images quickly and directing clinicians. 38 00:03:41,560 --> 00:03:45,620 And this has been articulated by John Bellis in the Life Sciences industrial section. 39 00:03:45,620 --> 00:03:53,140 He really sets digital imaging, and this process to streamline care is one of the key themes in that. 40 00:03:53,140 --> 00:03:58,570 And this leads us neatly onto the Insieme, which is an Oxford led partnership. 41 00:03:58,570 --> 00:04:06,130 The idea of time between clinical academic industry and old patient groups all together and fitting a sort of streamlined pipeline for innovation. 42 00:04:06,130 --> 00:04:10,960 So developing AI to also get an hour into practise and into commerce. 43 00:04:10,960 --> 00:04:21,460 And this was a really a direct response if I see the results of a large grant that came as part of the life sciences strategy. 44 00:04:21,460 --> 00:04:30,310 This is, as I said, is led in Oxford. And you can see this is a cluster of the various sort of spin off companies and products and academic partners. 45 00:04:30,310 --> 00:04:34,810 But actually, the network is right the way through the nation, and that's that's the fabric of this is something happening everywhere, 46 00:04:34,810 --> 00:04:45,970 not just in an isolated so that that gives you context and drives why we thought it was important to come talk to imaging all these 47 00:04:45,970 --> 00:04:53,500 these teams of exemplar projects we've got I've got a surgical leading to maybe wondering why I'm talking to surgeons about by the end, 48 00:04:53,500 --> 00:05:00,410 do you need all of these sort of surgical pathways? And so what we is, and I feel it, that's why it's one of our early success stories. 49 00:05:00,410 --> 00:05:04,930 Martin, thank you very much, Alex. 50 00:05:04,930 --> 00:05:11,770 I'm starting with a very simple and I'm going to talk about something that some of you may have seen in some time in your career, say Floyd. 51 00:05:11,770 --> 00:05:19,420 Injuries, which is a which is it's a it's an interesting little topic for EEG because it sounds very trivial injury. 52 00:05:19,420 --> 00:05:26,230 But yet it's one of the very few minor injuries that caused serious serious problems if we don't identify it. 53 00:05:26,230 --> 00:05:36,050 It's a hard injury to identify and. This is the paradigm that a child's right. 54 00:05:36,050 --> 00:05:43,580 This happens still in most emergency departments across the country, you come in with a little bit of wrist soreness. 55 00:05:43,580 --> 00:05:49,280 You put in a plaster for 10 of 14 days and then someone else comes in, look, looks at you. 56 00:05:49,280 --> 00:05:54,260 Now why has this happens? Well, it's happened for two reasons. 57 00:05:54,260 --> 00:06:00,450 Primarily, it's it's happened because. 58 00:06:00,450 --> 00:06:11,130 The thickest has been seeing the sickest, that's the old, the old talk, and that's unfair, but it's actually on trains. 59 00:06:11,130 --> 00:06:20,610 People are a very junior essay shows or whatever we call them now in the first few months of training in the position, 60 00:06:20,610 --> 00:06:25,290 they've seen this group of patients and they're not they're not by no means. 61 00:06:25,290 --> 00:06:32,100 The thing is they're just not trained. So we've been having the totally the wrong group of people saying this group of patients. 62 00:06:32,100 --> 00:06:40,920 And because of that, we then had to make sure that they got an expert review, which the decision was generally for other reasons or go on to. 63 00:06:40,920 --> 00:06:52,950 That was 14 days. The second reason actually the investigation that we do to look for this injury is not very good, and I'll come back to that. 64 00:06:52,950 --> 00:06:58,440 So in most departments, just to manage this horrible flow that that Alex has talked about, 65 00:06:58,440 --> 00:07:04,410 what happened was that any patient with any sort of vague form of wrist injury, 66 00:07:04,410 --> 00:07:08,400 and it was probably something totally different from escape as injury got stuck in the blast, 67 00:07:08,400 --> 00:07:12,510 the 14 days taken out were taken out tax free status or whatever, 68 00:07:12,510 --> 00:07:17,880 and then came back 14 days later to be reviewed in an easy clinic and a fracture clinic. 69 00:07:17,880 --> 00:07:26,280 Enormous cost to society, enormous cost to a lot of people. Quite a few patients actually got quite used to this and actually knew, well, 70 00:07:26,280 --> 00:07:33,470 if I just for my emergency department, I'll get put in plaster and I'll have two weeks off work. 71 00:07:33,470 --> 00:07:37,490 So not a good treatment, they're not, so we got Oxford's always a bit different, isn't it? 72 00:07:37,490 --> 00:07:39,320 And Oxford was very different here. 73 00:07:39,320 --> 00:07:46,910 So many of you will remember twenty five years ago, Peter Waller and Keith Willett designed this trauma service and the trauma service. 74 00:07:46,910 --> 00:07:51,170 One of the one of the things was every patient with the fracture will be reviewed the next day. 75 00:07:51,170 --> 00:07:55,430 So there was an expert review the following day, 76 00:07:55,430 --> 00:08:01,250 which got rid of a few of the patients because they identified that there were some other injuries in that. 77 00:08:01,250 --> 00:08:09,020 But still it was so many coming back two weeks later for later examinations that didn't work quite well. 78 00:08:09,020 --> 00:08:17,440 And now my trauma colleagues said to me, actually, we're seeing one of these patients every day with a little bit of soul rest in these clinics. 79 00:08:17,440 --> 00:08:20,940 You know, we see a one a day. We're not very good at it. We don't really know what's going on. 80 00:08:20,940 --> 00:08:25,970 We're not kind of specialists. We can't make the diagnosis. How do you sort it out? 81 00:08:25,970 --> 00:08:34,320 So we went back and thought, Well, what could we do differently? Nice has says two things about this injury. 82 00:08:34,320 --> 00:08:42,630 It says you should have early expert review, so away from the sickest for the thickest, the thickest. 83 00:08:42,630 --> 00:08:48,170 It said you should consider one morally. So they were the faces of all of. 84 00:08:48,170 --> 00:08:55,340 So we introduced this new algorithm, this is the first part of its patients who presents with a suspected psych ward injury. 85 00:08:55,340 --> 00:09:02,450 If you have three positive signs and the signs are very straightforward, sensitive, so began someone called snuff box. 86 00:09:02,450 --> 00:09:12,800 Send this over to Skype or cubicle and pain telescoping thumb if you have any of those signs, a significantly positive fit in the first. 87 00:09:12,800 --> 00:09:24,840 So you should discuss the patient with a senior to get the senior review and or deciphered X-rays. 88 00:09:24,840 --> 00:09:31,740 The reason the city discussion that is you don't want everyone getting scapegoated extra if you get an x ray, 89 00:09:31,740 --> 00:09:42,080 you almost committed to your treatment pathway. The expert we put on the ABC is that and we've now changed that, so we realise we've got a much, 90 00:09:42,080 --> 00:09:46,700 much better expert group and then does most of this work is now done by an 91 00:09:46,700 --> 00:09:54,220 emergency nurse practitioners who to all manage virtually all of these patients. 92 00:09:54,220 --> 00:10:00,610 You see them in the orange and red group, they're not seen with Coconino, right? 93 00:10:00,610 --> 00:10:07,750 Then the patient goes home and has their MRI, and it's a very straightforward pathway. 94 00:10:07,750 --> 00:10:11,860 And it's been in process for about a year now. 95 00:10:11,860 --> 00:10:18,070 I must show you some of the figures from the first few months and a little bit about the first year. 96 00:10:18,070 --> 00:10:24,040 But first of all, let's look at some of the X-rays just to show you how difficult this is. 97 00:10:24,040 --> 00:10:27,850 You know, this comes a little bit back to what Alex is saying about machine reporting. 98 00:10:27,850 --> 00:10:32,770 I'll be quite happy if we have machine reporting of these films because we're crap at it. 99 00:10:32,770 --> 00:10:37,480 Radiologists a crack at it. I reporter, I'll be honest, you know, 100 00:10:37,480 --> 00:10:45,980 because I know because I've seen the MRI results afterwards and you actually look in that get your report really means relatively little. 101 00:10:45,980 --> 00:10:52,550 So that's that's one film. This is a scapegoat. 102 00:10:52,550 --> 00:10:56,250 See, it looks. It's quite nice here. 103 00:10:56,250 --> 00:11:02,850 Perhaps a suggestion this is reported as normal is a bit of a cubicle on the side, perhaps a suggestion there's something going on there. 104 00:11:02,850 --> 00:11:09,660 Reports it is normal, but when you see the MRI facilities, often it's all this soft tissue swelling of marrow oedema. 105 00:11:09,660 --> 00:11:14,180 They're not that important injury. That injury would heal quite well. 106 00:11:14,180 --> 00:11:21,910 But it wouldn't have been spotted in the old system. It's another one beautiful looking sky boy looks smooth. 107 00:11:21,910 --> 00:11:29,200 That's probably normal. Was reported as normal by both us and the radiologists. 108 00:11:29,200 --> 00:11:34,470 But you look at it a little bit closer to town, this bottom bit here. 109 00:11:34,470 --> 00:11:40,530 Maybe there's a line there. Retrospect, the scope and the retrospective scope shows, if you look at it, 110 00:11:40,530 --> 00:11:47,110 that is just a big fracture through a bit of a scale it that you would not expect. 111 00:11:47,110 --> 00:11:54,540 Significant injury, because that may well get a vascular necrosis, a useless hands. 112 00:11:54,540 --> 00:12:02,100 And there it is on the seats, which the insurgents, Chris Little and his group used to monitor healing. 113 00:12:02,100 --> 00:12:07,150 A few weeks later, showing the fracture quite clearly at the base of the skateboard. 114 00:12:07,150 --> 00:12:15,960 This one, perhaps is, I think, is the most worrying because it looks entirely entirely normal, and I would. 115 00:12:15,960 --> 00:12:22,330 Assure you that 100 percent of machines, 100 percent of people would report that as normal. 116 00:12:22,330 --> 00:12:28,570 And yet, as the MRI, which shows the fractures through the waste escape a very significant injury, 117 00:12:28,570 --> 00:12:35,410 if this isn't treated very, very carefully, the patient could end up with a useless rest. 118 00:12:35,410 --> 00:12:39,640 So that's why we're doing it. That's why we need this in the classification. 119 00:12:39,640 --> 00:12:48,560 That's why we need to get the right group. Having this investigation, an easy, easy is like a Harry Potter sorting hat. 120 00:12:48,560 --> 00:12:51,260 That's what we do. We sought patients out. 121 00:12:51,260 --> 00:12:59,450 We drop them in to the right path and hopefully we treat most of them, 78 percent of them and get them home without any follow up. 122 00:12:59,450 --> 00:13:06,050 So this is our first 50 patients. We analyse this before and we thought we'd get about one day and we're right. 123 00:13:06,050 --> 00:13:10,660 Forty seven days you have 50 patients, male female split is about half. 124 00:13:10,660 --> 00:13:14,490 Most of them are correct. In the park where we started, we were putting a few too many. 125 00:13:14,490 --> 00:13:19,370 So we corrected that. It's about what I'm talking about x rays. 126 00:13:19,370 --> 00:13:26,690 We thought that 80 percent of the X-ray connective outside the radiology, but it was the same 80 percent was only 80 percent agreement. 127 00:13:26,690 --> 00:13:32,680 So actually, reportings, you know, it really doesn't mean anything if anyone thinks it's normal, low. 128 00:13:32,680 --> 00:13:40,240 The patient goes on to get an MRI, so this failsafe that you wouldn't think something's abnormal weakness abnormal. 129 00:13:40,240 --> 00:13:44,620 The patient goes straight into a fracture that gets followed. Accept fail safe in radiology. 130 00:13:44,620 --> 00:13:48,400 Thinks it's normal, but we don't get anyway. The patient's already gone to a fracture mix. 131 00:13:48,400 --> 00:13:55,320 It always feels safe. But this is showing you actually reporting doesn't have much value. 132 00:13:55,320 --> 00:14:03,890 And this injury is not a very good investigation. So 76 percent of the first 15 Typekit ended up having, you know, the rest of them, 133 00:14:03,890 --> 00:14:09,500 they were in the flight or they had a fracture of the skateboard, already 48. 134 00:14:09,500 --> 00:14:15,430 And so we've got straight into the neck or hands on it or. 135 00:14:15,430 --> 00:14:20,910 The head injury of another bone that went straight into a fracture connector. 136 00:14:20,910 --> 00:14:32,760 Of those group, the 76 percent, so probably the 35 patients who had the MRI, if you don't have it, it's because they say. 137 00:14:32,760 --> 00:14:40,350 And we contacted all of these, oh, I've actually better now. And so before they got the MRI, they said that they're better. 138 00:14:40,350 --> 00:14:47,840 We've written to them and said, if you've got any ongoing symptoms, you must come back. 139 00:14:47,840 --> 00:14:55,430 This is a slide I'm most proud of, because it shows how effective this sorting is. 140 00:14:55,430 --> 00:15:03,200 Sixty four percent had the MRI. Seventy percent of our patients have got a true radiological injury, 141 00:15:03,200 --> 00:15:08,260 so that's quite a high pick up rate compared with most scans that people take out. 142 00:15:08,260 --> 00:15:15,610 Of those, nearly 30 percent have the diagnosis. We're looking for a scapegoat fracture. 143 00:15:15,610 --> 00:15:21,320 My managers are keen on this, but none of the patients come back to us. 144 00:15:21,320 --> 00:15:26,550 Half of them go to the Hanzlik. A few guys are practical because they've got other injuries. 145 00:15:26,550 --> 00:15:33,960 And about almost a third goes straight from MRI and don't come back to the hospital at all. 146 00:15:33,960 --> 00:15:39,870 So they come back once for their MRI and actually what happens from the MRI is all the MRI revotes. 147 00:15:39,870 --> 00:15:45,390 Results are reviewed by a hand specialist. I have one of these. 148 00:15:45,390 --> 00:15:51,730 If it's if the MRI because the patient discharge and sit on top of the. 149 00:15:51,730 --> 00:16:02,890 The practical facts behind. So 40 percent of this group of patients don't come back at all, so it's much more effective use of our resource. 150 00:16:02,890 --> 00:16:09,250 We the reason the big wait for MRI is only four days and six days. 151 00:16:09,250 --> 00:16:13,720 The patient knows that diagnosis. So this is what Alex was saying. 152 00:16:13,720 --> 00:16:18,520 We're bringing back the diagnostics to the place they should be. 153 00:16:18,520 --> 00:16:23,950 We're making it timely. We're improving patient care. And actually, we've done this with what cost. 154 00:16:23,950 --> 00:16:29,440 No cost has been no funding. Nothing else has happened. We've just changed it. 155 00:16:29,440 --> 00:16:38,890 We've probably added more. We have added a slight MRI burden, but we've decreased the clinic burden across the organisation. 156 00:16:38,890 --> 00:16:45,370 First, yeah, I'm just looking at the first year. There's lots of other interesting stuff, we're picking up enormous amounts of other injuries, 157 00:16:45,370 --> 00:16:49,720 which we don't know are significant or not at the moment. 158 00:16:49,720 --> 00:16:57,280 We're going to probably change our protocols at the high end of the high age group because the elderly don't get this injury. 159 00:16:57,280 --> 00:17:04,540 People less than 10 don't get this injury, so we probably need different protocols for that, and we're still still at the roughly the same number. 160 00:17:04,540 --> 00:17:09,620 So we're probably getting just about less than one a day and roughly five more eyes. 161 00:17:09,620 --> 00:17:22,730 We. It's always good to get some feedback, so this was an anaesthetic colleague from the trust who came in with this injury. 162 00:17:22,730 --> 00:17:26,330 And you need your rest. So do things to me satisfy you? 163 00:17:26,330 --> 00:17:30,500 So he was able to be reassured that he could go back to work. 164 00:17:30,500 --> 00:17:36,710 So taking appropriate investigations. Doing them at the right time. 165 00:17:36,710 --> 00:17:40,740 Sorting patients who were. 166 00:17:40,740 --> 00:17:57,030 Many questions to do with the treatment any more than the of warning that what we do now is whilst the patient is awaiting the MRI, 167 00:17:57,030 --> 00:18:01,680 which is average is four or five days, they get put in a future just in a splint. 168 00:18:01,680 --> 00:18:10,260 And so if if they get a confirmed fracture of the X-ray, they go straight into to escape the past and then straight onto a hand clinic? 169 00:18:10,260 --> 00:18:18,690 If we just can't see if you have a normal X-ray, we're getting a splint for five days and then they have that MRI following the MRI. 170 00:18:18,690 --> 00:18:25,470 If it's negative to come out with a splint and immobilise and immobilised, you know, eight, nine days earlier, which is better for them. 171 00:18:25,470 --> 00:18:30,180 The other ones go straight on to a fracture clinic or home clinic where they get put 172 00:18:30,180 --> 00:18:39,000 in escape would cost Chris Little and my hand surgeon colleague then manages these. 173 00:18:39,000 --> 00:18:46,830 They are managed in the cost. They have serial settings to look for the healing of the waste to the sky for it. 174 00:18:46,830 --> 00:18:51,760 And then some that don't, [INAUDIBLE] go on and they need they need a screw put in. 175 00:18:51,760 --> 00:19:02,950 So pretty much anything is the best advice is that all these numbers and on Earth very often. 176 00:19:02,950 --> 00:19:09,670 The largest drop in the bucket is always the best policy. 177 00:19:09,670 --> 00:19:14,010 Our. And that risks that. 178 00:19:14,010 --> 00:19:18,960 The substance of the possibility that that is something that is made up of you said I don't know. 179 00:19:18,960 --> 00:19:23,010 I think it's a really good question. Thanks. I know, I agree. 180 00:19:23,010 --> 00:19:29,340 We had some excellent with my radiology colleague has been fantastic in supporting this process. 181 00:19:29,340 --> 00:19:37,410 He had some doubts originally about whether we would pick up. False injuries by marrying too early. 182 00:19:37,410 --> 00:19:45,060 So our original policy was always when we first started was to put a delay of 48 hours in before the MRI actually by mistake. 183 00:19:45,060 --> 00:19:50,580 If you've got MRI on day one or day two and the injuries were picked up or no injury was picked up. 184 00:19:50,580 --> 00:19:55,350 So that is false. So we've already proved that that is false. So yes, you can. 185 00:19:55,350 --> 00:20:00,330 MRI for from from from moments one. 186 00:20:00,330 --> 00:20:04,620 X-rays are such a cheap investigation. 187 00:20:04,620 --> 00:20:13,020 I, you know, I doubt whether we should get rid of the plain X-ray because you could pick up all the things on it. 188 00:20:13,020 --> 00:20:17,640 But but perhaps this is okay for your X-rays is that as I've shown, it's you know, 189 00:20:17,640 --> 00:20:22,920 it's it's not really is the best we had 20 years ago, but it's it's no good. 190 00:20:22,920 --> 00:20:27,750 So perhaps it would be just wrist X-rays, which would show most of the risk fractures. 191 00:20:27,750 --> 00:20:35,830 And then if you suspect the more, I would love someone to buy a small part MRI for the front door. 192 00:20:35,830 --> 00:20:42,840 That, to me is the future, and that's where we'll be in another 10, 20 years. 193 00:20:42,840 --> 00:20:56,480 Thank you very much. Hello, I'm Lois brand, and I'm going to spend 10 minutes just talking to you about a work in progress, 194 00:20:56,480 --> 00:21:05,660 actually, this isn't the finished article like fills. This is a work in progress and I became interested in the management of elderly 195 00:21:05,660 --> 00:21:10,670 chest trauma a couple of years ago when we had a series of really quite significant 196 00:21:10,670 --> 00:21:17,150 cases which were missed either because of our lack of care in clinically 197 00:21:17,150 --> 00:21:23,480 assessing the patients or a lack of adequate imaging or a combination of both. 198 00:21:23,480 --> 00:21:32,930 And one of those was the Siri, unfortunately. So this is in the context of what we're understanding nationally as changing face of major trauma. 199 00:21:32,930 --> 00:21:37,550 So these are admissions in the last year to the trauma centre here. 200 00:21:37,550 --> 00:21:45,560 And the green people are the ones who have an injury severity score of greater than 15 and so classified as major trauma. 201 00:21:45,560 --> 00:21:51,650 And you'll see that over 40 percent of those are in the age group 65 plus. 202 00:21:51,650 --> 00:22:05,360 So what was originally sort of perceived to be an injury, a a problem of of younger, particularly male patients caused by high energy attacks? 203 00:22:05,360 --> 00:22:12,110 Mainly actually major trauma is now predominantly a disease of the older individual, 204 00:22:12,110 --> 00:22:20,570 and most of these major trauma patients are actually getting their trauma from a fall from standing height. 205 00:22:20,570 --> 00:22:29,630 So you can see from this graph here, the older you get, the more likely your trauma is to be sustained by a fall of less than two metres. 206 00:22:29,630 --> 00:22:36,300 Comfortingly, the older you get, the less likely you are to be shot or stabbed. 207 00:22:36,300 --> 00:22:41,070 And this causes a problem for us, as you can see as you digest this slide. 208 00:22:41,070 --> 00:22:49,890 That's our triage system. Our pre-hospital triage system is set up to very accurately identify those 209 00:22:49,890 --> 00:22:54,360 people who need a trauma team at the front door and need to be assessed early. 210 00:22:54,360 --> 00:23:04,800 We're very good at picking up major trauma in patients in a younger age group, but we are not good at picking up major trauma in people who are older. 211 00:23:04,800 --> 00:23:11,190 When we think about the number of people who come into our emergency departments here in the air and also across the Horten, 212 00:23:11,190 --> 00:23:15,570 we see about 100 older falls a week. 213 00:23:15,570 --> 00:23:20,550 And of those, a very tiny number will have sustained major trauma. 214 00:23:20,550 --> 00:23:27,780 We are not good at picking those up, and that's because of co-morbidities, particularly if they're cognitively impaired. 215 00:23:27,780 --> 00:23:34,590 It's more difficult. It's because of the fact that they might be on beta blockers and so don't mount a tachycardia response to their haemorrhage. 216 00:23:34,590 --> 00:23:39,990 It's because they've got smaller brains encased within their cranium, and when they have blood in there, 217 00:23:39,990 --> 00:23:45,180 they don't always show that so, so much as as a younger brain might, which might be more quickly squashed. 218 00:23:45,180 --> 00:23:50,640 So lots of reasons why we find it very difficult to pick these people up. 219 00:23:50,640 --> 00:23:58,320 And as a result of this, we manage these patients differently. Now, arguably we should be we should be managing these patients differently. 220 00:23:58,320 --> 00:24:08,060 They probably don't need a full trauma team response, but they do need to be identified early and managed appropriately. 221 00:24:08,060 --> 00:24:11,120 Tom, have recognised that this is a significant problem, 222 00:24:11,120 --> 00:24:19,160 because the way that we've set up our major trauma response across the country is really targeted to the lower age group and high energy trauma. 223 00:24:19,160 --> 00:24:23,660 But this is now a big problem with our older patients. 224 00:24:23,660 --> 00:24:32,690 So they did a they looked at what we were currently doing across the UK and produced this report in 2017 and found that the 225 00:24:32,690 --> 00:24:39,170 older trauma patient is less likely to come to the major trauma centre and substantially denied access to the expertise. 226 00:24:39,170 --> 00:24:43,160 They're more likely to be treated by a junior doctor because when these bullies come in, 227 00:24:43,160 --> 00:24:47,090 they just next to be seen next to be seen by the junior doctor, 228 00:24:47,090 --> 00:24:56,990 who probably will not realise that these patients have got to be looked at very, very carefully in order to rule out major trauma. 229 00:24:56,990 --> 00:25:01,010 More likely to have delayed investigation is less likely to have surgery more likely to die. 230 00:25:01,010 --> 00:25:08,320 However, in the survivors, there's only a little bit more disability than in younger patients. 231 00:25:08,320 --> 00:25:13,270 So specifically thinking about imaging on in chest trauma in the older patients. 232 00:25:13,270 --> 00:25:21,230 We know that plane films are useless when we're dealing with major trauma, so we don't even bother with them if we have a trauma call. 233 00:25:21,230 --> 00:25:28,540 And we're seeing the patient in rhesus and they've been hit by a bus. We might do quick, a very quick chest and pelvic X-ray. 234 00:25:28,540 --> 00:25:31,840 There's not going to slow us down at all actually in recess. 235 00:25:31,840 --> 00:25:36,730 But then we will move very quickly once the patient is stabilised and within 30 minutes to doing a 236 00:25:36,730 --> 00:25:42,430 whole body CT scan because we know that's the only way we're going to pick up significant injury. 237 00:25:42,430 --> 00:25:50,950 However, as we've already said, the older patients there are lots and lots of them, and they're sustaining these traumas by a low force mechanism. 238 00:25:50,950 --> 00:25:59,440 And and we need to find the needle in the haystack. Chest X-rays are, we know, inadequate to pick up a lot of these injuries. 239 00:25:59,440 --> 00:26:06,640 So we were left with a real problem that we couldn't ask radiology to pick up the slack here and scan everybody. 240 00:26:06,640 --> 00:26:11,800 We needed to try and find a way of working out how to identify the patients 241 00:26:11,800 --> 00:26:16,360 who needed cross-sectional imaging without breaking the radiology department. 242 00:26:16,360 --> 00:26:22,330 So the first thing that we did was identify some key questions and we went to the literature. 243 00:26:22,330 --> 00:26:27,340 So the first question was how does chest trauma in the elderly differ from that of the general adult population? 244 00:26:27,340 --> 00:26:33,970 And the literature is quite clear on this. There were three key papers that that we focussed on, 245 00:26:33,970 --> 00:26:39,880 and it says elderly patients who sustained blunt chest trauma with rib fractures have 246 00:26:39,880 --> 00:26:45,010 twice the mortality and thoracic morbidity of younger patients with similar injuries. 247 00:26:45,010 --> 00:26:51,730 And for each additional rib fracture in the elderly, mortality increases by nearly 20 percent and the risk of pneumonia by nearly 248 00:26:51,730 --> 00:26:56,830 30 percent in elderly patients are prone to complications with rib fractures, 249 00:26:56,830 --> 00:27:05,820 even when minor trauma was the cause. So just identify clinically significant injury missed on Chest X Ray. 250 00:27:05,820 --> 00:27:11,040 This was more difficult to answer because there were no papers that look specifically at the older patients, 251 00:27:11,040 --> 00:27:16,350 but looking at a couple of papers that did this address this question in adults, 252 00:27:16,350 --> 00:27:26,160 it was clear that CTE detected clinically significant injuries and up to 50 percent of rib fractures are missed on plane x ray. 253 00:27:26,160 --> 00:27:30,150 Does early identification of these injuries positively impact the clinical course? 254 00:27:30,150 --> 00:27:33,900 I mean, this was a key question to answer for our radiology colleagues who didn't want 255 00:27:33,900 --> 00:27:37,680 to be doing these seats just so that we could get an accurate diagnosis, 256 00:27:37,680 --> 00:27:40,140 but it wouldn't actually change the management. 257 00:27:40,140 --> 00:27:45,300 And there were four papers that we looked at here one perspective what do you retrospective and a literature 258 00:27:45,300 --> 00:27:51,000 review that looked at this question and all concluded that early identification and aggressive pain management, 259 00:27:51,000 --> 00:27:58,050 physiotherapy and where appropriate, surgical fixation improves morbidity and mortality in these elderly patients. 260 00:27:58,050 --> 00:28:05,940 The final question What identifies patients who would benefit from this CT chest is, as you would imagine, the most difficult question to answer. 261 00:28:05,940 --> 00:28:09,930 There were two papers that came some way to addressing this, 262 00:28:09,930 --> 00:28:16,890 but it wasn't terribly clear how we were going to be able to sift out this needle in the haystack. 263 00:28:16,890 --> 00:28:25,920 So we did our best from taking what we found in the literature to try and come up with a clinical decision tool to aid our 264 00:28:25,920 --> 00:28:34,860 clinicians in the EDA to decide who should get a scan after reading the literature and and having this series of misses. 265 00:28:34,860 --> 00:28:42,870 I just wanted everybody who fell over who had got chest tenderness to have a CT, but that was clearly going to be a non-starter with the radiologists, 266 00:28:42,870 --> 00:28:48,990 who are very overwhelmed already by the amount of work that they're doing for us. 267 00:28:48,990 --> 00:28:58,890 So we put together this guideline and have since then reviewed the guideline and and seen what the effect has been. 268 00:28:58,890 --> 00:29:07,200 He once was. We've done this on the patient and identified the injuries in the chest wall as a plain CTVNews. 269 00:29:07,200 --> 00:29:16,590 We don't use contrast CT for these patients. We can then calculate the battle score, which then informs their onward management. 270 00:29:16,590 --> 00:29:21,390 So the battle score is is a it's it's been. 271 00:29:21,390 --> 00:29:29,850 What's the word? It's a what's the word Alex beginning with L and I'll come back to that anyway. 272 00:29:29,850 --> 00:29:38,070 It's that the battle score is well recognised as a tool to help stratify risk in patients with chest wall injury. 273 00:29:38,070 --> 00:29:43,620 And you'll see from here that we have a guideline which suggests that those with minor injuries can go home. 274 00:29:43,620 --> 00:29:52,590 Those with a moderate battle school can be admitted for pain relief and mobilisation under the medical team, 275 00:29:52,590 --> 00:29:57,540 and anybody with a better score of 21 or more will be discussed with their thoracic team. 276 00:29:57,540 --> 00:30:03,720 And there is some flexibility here. Those who are not needing fixation and who the cardiothoracic team think can be managed 277 00:30:03,720 --> 00:30:09,270 under the medical team can then be discussed with the medical team and managed through them. 278 00:30:09,270 --> 00:30:16,390 And that's often the best pathway for those who are not going to have surgical fixation. 279 00:30:16,390 --> 00:30:24,760 So these are some of our numbers, we looked at six months of data before we implemented the guideline is six months after those of you who 280 00:30:24,760 --> 00:30:29,800 are still conscious will notice that the numbers before are significantly lower than the numbers after. 281 00:30:29,800 --> 00:30:34,450 I don't think that represents the fact that we had more patients during that six months. 282 00:30:34,450 --> 00:30:38,140 It's just unfortunate that in between the pre and the post, 283 00:30:38,140 --> 00:30:46,510 we had a complete change in the way that we recorded data about patients diagnosis within the department and that was beyond our control. 284 00:30:46,510 --> 00:30:55,120 It does mean, however, that these sorts of things are now much easier to look at, but it means that it's difficult to compare accurately pre and post. 285 00:30:55,120 --> 00:31:04,900 But what you can glean from here is that a greater proportion of patients had a CT scan afterwards than before, but it's not a huge increase. 286 00:31:04,900 --> 00:31:10,270 You'll also see in the post and numbers that quite a few had a chest X-ray first, 287 00:31:10,270 --> 00:31:15,040 and that's not what we would have wanted to happen, because that's probably not really very useful. 288 00:31:15,040 --> 00:31:19,750 I think that when the patients need an image, then they need CT here. 289 00:31:19,750 --> 00:31:23,290 We're not adding anything by doing the chest X-ray, but you'll see that it's actually quite useful. 290 00:31:23,290 --> 00:31:25,270 We wouldn't have been able to put that through ethics to say, 291 00:31:25,270 --> 00:31:31,840 we want everybody to have a chest X-ray so we can compare whether the city really is picking up something that's more useful, 292 00:31:31,840 --> 00:31:37,600 but that that little which there on the right is actually quite useful for us, as it turns out. 293 00:31:37,600 --> 00:31:44,080 So of the patients who had a city at the numbers was 65 post implementation. 294 00:31:44,080 --> 00:31:49,240 You will see that out of those 65, only nine of those were no more so, but a massively high pick up rate, 295 00:31:49,240 --> 00:31:55,150 which makes me feel very anxious that we are missing significant patients. 296 00:31:55,150 --> 00:32:02,890 None of the patients in the six month period came back with something related that weren't picked up on CT. 297 00:32:02,890 --> 00:32:10,060 But these are small numbers, so you can see we're picking up an enormous amount of chest pathology. 298 00:32:10,060 --> 00:32:17,560 This is the slide that I mentioned where these 27 patients who happened to have both Chest X-ray and CT. 299 00:32:17,560 --> 00:32:28,750 We compared the findings of the two. And as you can see here, we are picking up significant injuries on the C.T., which are being missed on the X-ray. 300 00:32:28,750 --> 00:32:34,450 The other thing which I think is important is that when we looked at the data 301 00:32:34,450 --> 00:32:41,290 retrospectively and looked at the number who met the criteria on the guideline, 302 00:32:41,290 --> 00:32:46,090 I mean, it's obviously difficult to be accurate because you're looking back at the notes rather than seeing the patient in front of you. 303 00:32:46,090 --> 00:32:54,790 But looking back of the 62 people who met the criteria for scan, two thirds of those was scanned. 304 00:32:54,790 --> 00:33:01,540 And of the 65 patients who didn't meet the criteria for a scan, one third of those were scanned anyway. 305 00:33:01,540 --> 00:33:07,450 And of those about a half, we found significant injury and which makes me think again. 306 00:33:07,450 --> 00:33:18,560 We need to rethink this guideline and lower the threshold even more for scanning in this group of patients. 307 00:33:18,560 --> 00:33:21,110 So looking forward, we're going to continue reviewing the data, 308 00:33:21,110 --> 00:33:28,310 further developing the imaging guideline and ongoing education of our of our clinical staff is obviously really, really important. 309 00:33:28,310 --> 00:33:31,970 Unless you undress these people and go over them with a fine tooth comb, 310 00:33:31,970 --> 00:33:41,010 you are going to miss significant injury and ongoing review and development of the inpatient pathways obviously key to this as well. 311 00:33:41,010 --> 00:33:47,910 OK, I'll take questions at the end after yours. Thank you very much. Thank. 312 00:33:47,910 --> 00:33:51,210 And prove it. OK, 313 00:33:51,210 --> 00:33:57,450 so I'm going to just give you a quick before we take some questions of these and just kind of run through very quickly through to further projects 314 00:33:57,450 --> 00:34:06,360 about both of which actually bring a collaboration with surgical colleagues say the first of these is a small pilot asked to be put together. 315 00:34:06,360 --> 00:34:12,210 And this is based around imaging pathways and to keep ghost with suspected acute ghost and presentation. 316 00:34:12,210 --> 00:34:15,930 So no news to anyone here that gallstone disease is really common. 317 00:34:15,930 --> 00:34:20,730 This is a prevalence of around 50 percent in the population in the developed world. 318 00:34:20,730 --> 00:34:29,220 There's three sort of key imaging modalities, so ultrasound, which is very operate, is relatively cheap. 319 00:34:29,220 --> 00:34:37,860 Out of the three, very operator dependent a lot of noise and signal and is often quite insensitive to picking up some of the gallstones himself. 320 00:34:37,860 --> 00:34:42,030 And then, he said, issues with the common bile duct, those LCP, 321 00:34:42,030 --> 00:34:48,120 which is obviously very invasive and expensive, tends to require admission or at least a day case. 322 00:34:48,120 --> 00:34:48,690 And again, 323 00:34:48,690 --> 00:34:58,620 quite a lot of intraoperative variability and in the current gold standard is another step which is very good to of sensitivity and specificity, 324 00:34:58,620 --> 00:35:01,560 Finkelstein disease and the complications around it. 325 00:35:01,560 --> 00:35:11,070 It's non-invasive, considered expensive, but actually coming down in price and in most of the stage is actually a similar similar cost to ultrasound. 326 00:35:11,070 --> 00:35:20,790 Again, is somewhat qualitative, and it relies a lot on the judgement of a radiologist to say whether the bile ducts are dilated or not. 327 00:35:20,790 --> 00:35:27,930 So one of the companies working in Oxford is perspective, where we have a sort of research relationship, 328 00:35:27,930 --> 00:35:34,380 and they came up with an algorithm for interpreting and MCP quantitatively. 329 00:35:34,380 --> 00:35:40,980 This is being used in things like primary sclerosing cholangitis, fatty liver disease, looking at vibrations. 330 00:35:40,980 --> 00:35:45,210 One of the perhaps the less sort of more marginal possibilities, though, 331 00:35:45,210 --> 00:35:51,090 is to look at the biliary tree itself and actually find some quantity quantitative imaging for as an objective finding. 332 00:35:51,090 --> 00:35:53,940 And you get images like this, particularly one on the end. 333 00:35:53,940 --> 00:35:59,220 You can see the sort of red hot spots and these these different colours reflect different diameters. 334 00:35:59,220 --> 00:36:08,740 And it's actually possible to get a score for an overall dilatation or otherwise of the bilby dream and predict the detective struction. 335 00:36:08,740 --> 00:36:15,240 And what? Why is this relevant as well? We became interested in pathways for these patients in terms of imaging, 336 00:36:15,240 --> 00:36:22,050 and most people realise the standard sort of test of choice in an age has been in the ultrasound scan. 337 00:36:22,050 --> 00:36:27,430 The idea is that, you know, this can be fairly quickly and cheaply discharge. 338 00:36:27,430 --> 00:36:30,120 Make a decision whether or not they need an MRI scan. 339 00:36:30,120 --> 00:36:38,370 If there's any suspicion of any obstruction further up, the ultrasound is not sufficient to give you the full diagnostic picture. 340 00:36:38,370 --> 00:36:40,770 And we ran a six week the disclaimer. 341 00:36:40,770 --> 00:36:45,840 This is about three years ago and things have shifted quite considerably with the advent of ambulatory care in the ICU. 342 00:36:45,840 --> 00:36:51,970 But broadly speaking, you can see here there's about half out of sort of 36 patients. 343 00:36:51,970 --> 00:36:59,490 So roughly, you know, when one a day give or take, 27 of them see the option and these actually 14. 344 00:36:59,490 --> 00:37:03,810 So over half of them actually went on to have an MRI anyway. 345 00:37:03,810 --> 00:37:10,500 And the point about this is obviously there's there's not much value in doing an ultrasound in some of the ActionScript. 346 00:37:10,500 --> 00:37:12,360 If they're going to have to go on and doing more anyway, 347 00:37:12,360 --> 00:37:20,340 why not just do the MRI and this when you add in the time to reports and the admission times and the consequent length of stay like this? 348 00:37:20,340 --> 00:37:26,720 Well, it becomes quite a big economic problem. So again, the times of these probably improved over the last couple of years, 349 00:37:26,720 --> 00:37:31,380 but not dramatically was like twenty four hours to get an ultrasound report and up to about 40 hours. 350 00:37:31,380 --> 00:37:35,040 Neither of these are mean figures to get an MRI report, 351 00:37:35,040 --> 00:37:42,900 and this is a this is a big delay for patients in terms of complications and outcomes is also just a big admission burden. 352 00:37:42,900 --> 00:37:51,150 So we're putting our heads together collectively so between any spacing, altering surgery and quality, 353 00:37:51,150 --> 00:37:59,970 helping with radiology and supported by the prospective diagnostics, we put together a pilot project which is ongoing at the moment as very small. 354 00:37:59,970 --> 00:38:11,610 Just 64 patients split 50 50 between direct them LCP, so within 24 hours and Standard Care, which is when the clinician feels is needed. 355 00:38:11,610 --> 00:38:14,310 So this is ongoing as we speak in media. 356 00:38:14,310 --> 00:38:19,530 So what's tricky here in these kind of things is how you decide what your primary outcome is because of course, 357 00:38:19,530 --> 00:38:27,120 the length of stay may actually be increased by an MRI. If you if you find a complication that needs only you, that needs any LCP. 358 00:38:27,120 --> 00:38:34,590 So we came up with this sort of composite end point, which is the cost of final diagnostic reports and the cost of admission up to that point, 359 00:38:34,590 --> 00:38:37,470 which you get a diagnostic report, which then doesn't change. 360 00:38:37,470 --> 00:38:47,430 So that was sufficient to allow discharge when we're looking at some secondary outcomes, as well as the cost of admission patient outcomes and. 361 00:38:47,430 --> 00:38:54,360 Perhaps one of the more interesting drivers for this is the Explorer Chathams, all the patients who consented to have right to use their images, 362 00:38:54,360 --> 00:39:00,480 anonymized images to develop the algorithms looking at BBC itself so that the outcome was 363 00:39:00,480 --> 00:39:05,010 of whether we can perhaps develop a sort of validated quantitative measure of looking 364 00:39:05,010 --> 00:39:11,160 at the pill retrieval because essentially the inclusion criteria says adult patients 365 00:39:11,160 --> 00:39:16,920 suspected gallstone disease with acute abdominal pain and just anything mild intervention. 366 00:39:16,920 --> 00:39:25,920 All of these are about a 10 percent increase in the lefties. So fairly pragmatic at the moment we have about 14 patients recruited and we're looking 367 00:39:25,920 --> 00:39:33,300 to compete in spring next year and hopefully we'll be able to present more then. 368 00:39:33,300 --> 00:39:36,370 So that that's one of the projects I wanted to talk to you about, 369 00:39:36,370 --> 00:39:44,940 just because I'm aware with specific three or four time I've talked to you quickly about the next one, which is the critical care suite and the G. 370 00:39:44,940 --> 00:39:50,310 This basically is a mobile X-ray machine with embedded tech, which and again, 371 00:39:50,310 --> 00:39:56,310 the evaluation is ongoing now as we speak, and this has two key capabilities. 372 00:39:56,310 --> 00:40:05,010 One is image optimisation and one is picking up pneumothorax and prevalence in the 80s is fairly low, 373 00:40:05,010 --> 00:40:14,370 actually says five to seven for about 8000 to 10000 machines per from single antigenic and in primary spontaneous, it's about eight point six. 374 00:40:14,370 --> 00:40:20,310 So it's fairly low, but it's present in there. And of course, this excludes thoracic surgery. 375 00:40:20,310 --> 00:40:25,780 Patients eventually all have a pneumothorax when you open the chest. 376 00:40:25,780 --> 00:40:31,960 This is what we tend to be faced with the needy, and as you can see, if we're looking for inimical acts, 377 00:40:31,960 --> 00:40:35,050 we might be able to spot this here, but it's not something that leaps out of you. 378 00:40:35,050 --> 00:40:39,250 And certainly, if you were a junior reporter or someone in a hurry, you quite distracted. 379 00:40:39,250 --> 00:40:48,250 This is not always an easy one to spot. It was a frequent cause of the phone call, you know, sort of subsequent reporting. 380 00:40:48,250 --> 00:40:54,880 And of course, this is actually what we tend to see in any which is a chest x ray slumped over with all the other things going on. 381 00:40:54,880 --> 00:41:02,620 And every time there's a pneumothorax. So this this kind of illustrates the point where I could fit in terms of detection because she's the best 382 00:41:02,620 --> 00:41:07,870 one in the world is very tricky and is certainly tricky if you're not suspecting it in the first place. 383 00:41:07,870 --> 00:41:16,090 And this is the critical care suite. So this you can see here. This is the X-ray comes up with a point, a point of care image. 384 00:41:16,090 --> 00:41:21,580 And this has already been put together in the states. They've done their diagnostics. The stats are kind of interesting. 385 00:41:21,580 --> 00:41:27,280 So the over there, the ones I picked out, the the negative predictive idea was pretty good. 386 00:41:27,280 --> 00:41:31,960 It's pretty good at telling you if there isn't one, which actually for me is any doctor is actually the most useful thing. 387 00:41:31,960 --> 00:41:38,320 I want to know whether it's reliable, positive predictive value, considerably less so. 388 00:41:38,320 --> 00:41:45,130 But it's possible to tweak the sensitivity of the various configurable thresholds, depending on on how concerned you are. 389 00:41:45,130 --> 00:41:48,680 So this allows you to change depending on where, which particular you work, 390 00:41:48,680 --> 00:41:55,990 and it also has this intelligent auto rotate so as to avoid the kind of slumped image. 391 00:41:55,990 --> 00:42:04,390 So this enables the detector to interpret sort of standardised X-ray film, and it also improves it for the clinicians. 392 00:42:04,390 --> 00:42:10,210 So we're running a market valuation in this at the moment. This is in collaboration with Elizabeth during of Essex and Vegas, 393 00:42:10,210 --> 00:42:19,030 and the Insieme machines are already in place and I'm collecting images and we're looking at completing this in the next few weeks. 394 00:42:19,030 --> 00:42:24,250 Following on from this, we've put in ethics for perhaps the key question, 395 00:42:24,250 --> 00:42:29,470 which is is it any good in terms of detecting you with these over and above clinicians? 396 00:42:29,470 --> 00:42:39,100 So this is going to run a subgroup analysis where we look at different groups of clinicians, ICU docs, docs, radiologists, radiographers, 397 00:42:39,100 --> 00:42:44,980 nurses and different levels of seniority and just compare the algorithms against them, 398 00:42:44,980 --> 00:42:50,690 see to see what you see where it says, and we'll look to see that with that 12 months. 399 00:42:50,690 --> 00:42:57,010 This is pretty small fry stuff, but perhaps pneumothorax wouldn't be the most immediate thing. 400 00:42:57,010 --> 00:43:00,010 Grab everyone's attention here. But the point of this really, I guess, 401 00:43:00,010 --> 00:43:09,220 is proof of principle that this can be fairly quickly updated the the algorithms already in process Numa peritoneum factor. 402 00:43:09,220 --> 00:43:19,240 All these things are quite easy to miss on chest x rays, and this is what can we look to to replicate this for various other areas of the pathology? 403 00:43:19,240 --> 00:43:27,040 So that's it in terms of the presentation. So it's for projects or very different arenas as far as emergency medicines are concerned, 404 00:43:27,040 --> 00:43:32,260 but all involving the same kind of principles about bringing expensive tech early in the 405 00:43:32,260 --> 00:43:37,330 pathway to have an overall cost benefit and some indications of where technology might fit in. 406 00:43:37,330 --> 00:43:46,130 And you're likely to be seeing many more of these. Thanks very much and investment.