World Orthopaedic Concern
Newsletter No 172
June 2015
Distributed from - laurence.woc@gmail.com
Websites www.worldortho.com & www.wocuk.org
This Newsletter is circulated through the internet, and through all WOC Regional
Secretaries in the hope that they will be able to download and distribute it to those
“concerned” who may not be connected through the “Net.” It is addressed to all
interested in orthopaedic surgery, particularly in areas of the world with great
need but limited resources.
Still on the subject of the running sore in the Himalayas, we have a report from
Jopati, where the UK Expedition was set up. Steve Mannion, chief advisor to the
International Emergency Trauma Registry, (IETR) had made himself available
to respond with appropriate speed. As the leading operative, the IETR has been
instituted in several countries, not least at the Royal College of Surgeons in
London, to prepare Surgical Training for Austere Evironments (STAE).
Nothing is more essential to emergency care than the proscriptions of the “Acute
Trauma Life Support” based on the tragic experience of Dr James Snyder, an
orthopaedic surgeon, involved in a light aircraft crash in Nebraska, in 1976. ATLS was
devised at the Lincoln Medical Education Foundation, and is the basis for Primary
Emergency Care, throughout the world. The Certificate from the authority ranks as
importantly as that of any College of Surgery, although all its necessary facilities are not
universally available.
The “Golden Hours” of survival, following surgical shock, are described as
fundamental and essential. They rely upon instantaneous availability of
experienced and equipped ambulance staff. to sustain both circulation and
respiration. Since “Haiti”, lessons have been learned and demands made on a
broad scale, which are impossible to meet with regularity, because of the
unpredictability of geography. Restricted conditions have been met through the
Primary Trauma Course which makes fewer demands on complicated equipment,
and are therefore universally appropriate.
Steve Mannion explains, most natural and unnatural disasters occur in parts of
the world permanently deprived of technical equipment, and therefore in
immediate risk of lethal injury. The mobilisation of the British response team was
quick in terms of the logistics, but inevitably slower than that of Nepal’s immediate
neighbours. The experience and the surgical work of the team was reported to the
Annual Meeting of WOC(uk) on June 6th 2015, jointly by Steve Mannion and a
local Nepalese surgeon working at the Nepal Medical College, Jopati, namely Dr
Silag. Much of the MCN building was considered unsafe after the eruption, so
beds and operating facilities were set up in the underground car-park which had
stout supporting pillars. The major threat was from the damaged clock tower
which required the expert attention of the Royal Engineers, to prevent the total
destruction, were it to crash through the hospital roof.
The surgical work covered all phases of life preservation and reconstruction. The
statistics of the emergency work, modest in terms of National figures of lives
saved and fractures mended, were presented in relation to the overall tragedy.
Most of the surviving hospital institutions in the city, were able to provide a good
level of surgical expertise. The NMC now has to rebuild and repair.
Mr Mannion welcomed the change, from WOC(uk)’s priority for orthopaedic
education and training, towards the management of disasters of these dimensions.
He emphasised that most such emergencies occur in areas of the world with low
income and limited resources.
In his autobiographical statement at last week’s
meeting in Oxford, Mr Mannion describes his first-hand experience of the Earthquakes
and other calamities in Gaza, Pakistan, Angola, Sri Lanka, Ruanda, Cambodia,
Afghanistan, Libya and the Philippines.
The destruction by the storm “Halyan”, was a great triumph of simple domestic
construction, with the spirit of Survival. He added his appreciation for the truly
remarkable generosity of the whole world to the disaster. In fact local knowledge of
consequences lead the survivors of the disaster, immediately to set about the repair
homes, roads and drains, and to sow the seeds (literally) for the year’s crops, without
which the community ultimately collapses. The survivors were the stars. They are the
future on which the next generation will depend, and which will need all the help they can
get. Steve Mannion was able, through his many other Charity interests, to make use of
the money donated, in excess of that which could usefully be consumed, to fund other
projects, like club-foot clinics throughout the Philippines.
Tragic experience of deaths due to crush injuries, involving buildings, need immediate
heavy-lifting gear. In the presence of destroyed infrastructure, only the best equipped
military machine is able to make a significant difference, having the capability to gain
access where roads are disrupted. The fatality figures are related directly to the density
of population at the epicentre, and the weight and security of the building materials. Only
the accident of location, and the time of day, left Kathmandu with 8000 dead, whereas
Port-au-Prince suffered 200,000 fatalities.
The fastest response in Nepal came from India – immediate neighbours, and Bhutan, a
tiny mountain state. Next came the Israeli airborne military – the most prepared service –
constantly at the ready; but even that was days away. The UK team waited patiently, for
two days at Delhi Airport, for a landing slot to become available in Kathmandu.
Mr Steve Mannion gave his priceless experience as advisor to IETR, which has set up a
equipped base near Cardiff for instant deployment. But his own experience in Jopati
(NMC), was that Life Saving measures, were already complete, from several days after
the eruption, and structural repair was already proceeding, using the customary local
materials.
From Professor R K Shah; “Through the Napali fund, (v. i.) we are able to
support any surgeon/hospital in Nepal, to provide free treatment to the victims.
We have already developed working network of AO trauma surgeons from various
hospitals in Nepal at Nepalgunj, Tansen, Pokhara, Bharatpur, Birgunj, Janakpur,
Lahan, Biratnagar and Dharan.
We now have many trained and competent trauma surgeons across the country,
but they lack resources to provide free treatment.
The proposed fund will address this problem in the most cost effective manner for
appropriate fracture care of the victims, by the local surgeons and also to support
the visiting experts from all over the world.. I hope WOC will also support this
program.
I believe you will agree with me and advertise to attract the sponsors, donors and
expert participants.
Name of Fund: “Treatment Fund for Earthquake Victims:”
Host Place : Nepal Medical College, Jopati, Kathmandu, Nepal.
(Convenor : Prof. Ram K Shah.)
Ƒrom Professor Narinder Kumar Magu.
“We have just returned from Kathmandu, Nepal, part of a group, including Dr
Nadeem Faruque from Kanpur, organized by the by Indian Orthopaedic
Association, to help with a particular group of the earthquake victims. Prof HKT
Raza (co-ordinator, and past president IOA and APOA) took the initiative. At his
request the Government of Haryana State, immediately released me enabling us
to reach Kathmandu on 13th of May (day18, after the impact).
“A pilot pathfinder group had made the selection of 17 neglected fractures of
acetabulum and pelvis, two weeks after the event, awaiting both analysis and
reconstruction. Dr H R Jhunjunwal President IOA, with Dr Sanjay Jain,
Secretary of the Association, comprised the approval authority.
“There were 15 females including four children and two males. We visited
Tribhuvan University Teaching hospital. Four patients underwent major surgery.
This included combined anterior and posterior surgical approaches to manage the
anterior column, posterior hemi-transverse fractures and three neglected vertical
shearing sacro-iliac dislocations. Eleven were treated conservatively.
“We are happy to serve the ailing patients and are always ready to do so as and
when our services are required. The expenses for implants were born by Indian
Orthopaedic Association including our travel expanses, and we thank the Govt. of
Haryana, India, for giving us the opportunity to be there. The surgeons of TUTH
helped us in the completion of the surgery, and to initiate the rehabilitation.”
(Professor N K Magu)
This is a good example of well organised specialist management, with advance
planning. It is rarely a part of the initial surgical response. It requires experience of
an uncommon condition, where speed is less important than judgment. Curiously
this delay is probably beneficial for careful reconstructive surgery, after the
haemorrhagic phase; (although it is possible that several may have died waiting
for the team to arrive). The first wave of acute trauma is over, but there will long
be the need for the “routine trauma load” to be dealt with, while the exceptional
commitment is receiving attention.
-o0o-
The LANCET is to be applauded and thanked for its Campaign to promote the
fundamental need for universal care, managing conditions that are commonly
regarded as Surgical rather than Medical. The distinction is historical and
unhelpful. Two important and well attended meetings have taken place, in
Amsterdam last year, and in London in April this year. The listed presentations
were excellent and the involvement from the “floor”, animated and constructive.
They have been referred to in previous editions of this Newsletter, but this week
we received the Amsterdam Declaration on Essential Surgical Care, the
definitive distillation of the debate, upon which further comment is appropriate.
In its introduction, the “Lancet statement reads:“The situation with regard to a lack of surgical capacity in LMICs is untenable, and
urgent action is required to alleviate the situation. Many thousands of patients are
dying unnecessarily every day because there is no one trained to operate on
them. As a consequence, the death toll of surgical conditions in low resource
settings, currently outnumbers the death toll from HIV, Malaria and TB combined.
“Rarely has there been such unanimity in the field of global surgery, and urgent
action is needed.
The lack of surgical care will be on the agenda during the
World Health Assembly in May 2015. We solicit international health policy
makers to support the initiative towards a WHA resolution on “Strengthening
Emergency and Essential Surgical Care, with Anaesthesia as a fundamental
component of Universal Health Coverage.”
“The world has to realize that we have completely forgotten something:! Surgery
should be part of the United Nations’ post-2015 sustainable development
goals, as an essential and named component.”
The declaration goes on to list the many pressing requirements for Essential
Surgery to be provided. They group the raw statistics of poor health service, with
which there is no doubt. It includes all manner of pathology; but from a surgeon’s
viewpoint, the shortage is predominantly one of teaching and training. In the
medical schools of the West, the biology (pathology and physiology) has been
usurped by the application of complicated technology. The breadth of Medical
(including Surgical) Science has been subsumed by manufacturing industry –
whose achievements are to be celebrated and admired. It is a fact of medical life
that Life expectation has advanced hugely; and that would not have occurred but
for the ingenuity and inventiveness of surgeons and engineers. But the danger
has been that the most simple medical skills have been neglected.
For those concerned and engaged in the support of mankind’s pathology, a
dilemma develops in the care for simple conditions which may destroy the
working capacity of individual clinics. Where is to be found the instruction of basic
techniques for the preservation of tissue, and life?
Lancet’s Appeal is for the support of the Governments of every Nation, the
UN, the WHO, the World Bank, Institutional donors, as well as nongovernmental organisations, colleges, professional bodies and all involved
medical and surgical societies.
The Declaration defines the Essence of Urgent Surgery as including the
following interventions; not as instruction to “Intervene”, but to understand
the reasons, the indications and the techniques of performance.
Based on Trauma, as the typical example, there is a need for responsibility to be
built into medical Training. For example how many of us would feel confident to
perform a caesarian section, nor even to set up an intravenous drip on a patient
with collapsed circulation, to instill an central venous line, to intubate the trachea,
to find and tie a torn artery, to deal with apnea, or to suck out the throat? In our
comment, I have taken the liberty of introducing brackets ( ) to indicate that there
is still debate as to whether some of these items should be included as part of a
general requirement. This is not a criticism of their real value, but an attempt to
categorise
Of all these requirements, the “Caesar” is the most common, the most urgent and
the most instantly demanding of all surgical procedures. Its frequency maintains
operating theatres in a constant state of preparation.
Interventions, Essential and Urgent.
Management of the compromised airway. Tracheal intubation; Removal of pharyngeal
foreign body. Release of Tension Pneumothorax( Tracheostomy, cricothyroidotomy).
Management of haemorrhage. Pressure dressings; establishing access to a vein, in a
collapsed patint. Instillation of a central venous line.
Caesarean section. Assisted or manipulative delivery. Evacuation of retained
products of pregnancy. (Symphysiotomy,)
Reduction of limb fractures and dislocations; casting and splinting, external fixation:
Vascular complications-; compression ischaemia, compartment syndrome, fasciotomy.
tenotomy and release of contracture.
Amputations. Sequestrectomy, and biopsy of
bone tumour.
Abdominal Laparotomy. Removal of ruptured spleen, and ectopic pregnancy.
Appendicectomy; bowel repair, and drainage. Hernia reduction and repair.
Management of head injury, (cranial burr holes, elevation of depressed cranial
fracture.)
The management of skin wounds including burns: Debridement, haemostasis, skin
suturing, (incl. when not to…). Escharotomy, skin grafting, vascularised flap transposition.
To establish Drainage. of abscess, of urinary bladder, of haematoma & haemarthrosis;
paracentesis, empyaema, pleural effusion; (tympanotomy),
I have deleted some for lack of urgency or the need for special training e.g. -- Cataract
surgery, and lens extraction; dental work, etc. But this is to interfere with the excellent
work of the “Global Surgery Initiative”, which must be the basis for continuing discussion.
All these remarks refer to the single-handed surgical service; (not for the uninitiated; and
midwives perform Caesars in many places). They must not be considered a requirement
for all who offer help in the deprived parts of the world, nor dissuade anyone from the
priceless service for those areas with no surgical care. . .
-- to be continued.---comments invited.
(M. Laurence)