World Orthopaedic Concern
Newsletter No 174
July ii 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 those who work in areas of the world
with great need, and very limited resources.
WOC has no single philosophy, but the spread of Service to the world’s underresourced areas, whose population has little or no access to orthopaedic care.
The stages of provision vary widely, many lacking complicated tools, some lacking
a sterile environment for implants, many lacking consumables, such as pins and
screws, even more lacking experienced supervision. There is therefore a duty to
try to bridge these several Gaps. There is no place for blind charity, where the
knowledge is lacking.
Teaching under varying circumstances, calls for great flexibility. There still seems
to be an air of ‘competition’, like that which used to characterise
undergraduate teaching of Medicine vs. Surgery -- Conservative vs.
Operative treatment.
In a previous Newsletter, Louis Deliss wrote (NL 171), “After all other
factors have been considered, and only then, can any decision about
management honestly be made. Too often the treating doctor, especially if
he is an orthopaedic surgeon, jumps to choose a treatment that will interest
him, one that is in the current fashion or will bring him financial reward, . !! ”
“We must stop discussing the simplistic choice between operative and nonoperative treatment. Even when both can be appropriate, and all the
conditions are in place there remains “choice”. These points must all be
honestly assessed? The current debate implies that operative treatment is
always superior to non-operative, it is not. Nor is a conservative option
always the easiest. Each patient deserves that the treatment method
proposed be fully assessed for appropriateness.”
The duty of the visiting teacher/trainer might require teaching a different
style than that with which he or she is familiar, adjusting to unknown
circumstances. Ideally the visitor will be well known to the host and be
invited for a specific function. The visitor with a commercial link may not be
appropriate. Unpredictability calls for ingenuity; nowhere is this more
essential than in the case of Trauma. A very great deal of necessary
reconstruction stems from long-neglected fractures or dislocations. But the
heat of Trauma presents even greater difficulties.
-o0oLife and death decisions are often made in the first few minutes of a sudden,
serious accident. But the actual diagnosis of death is the most responsible
decision, and there is never anyone at the scene with the knowledge or
experience to make that decision with confidence. Death must never be assumed
without some attempt at resuscitation. When an accident happens (and by
definition it is unexpected) the person nearest to the victim has the best
opportunity of saving his life; and he or she will never have been in this position
before.
The Big Impact of Major Trauma.
On July 22nd, the President of the R.C.S., Clare Marx, established an initial
discussion seminar, held in the Council chamber, to introduce the work of the
Education Faculty of the College. A small invited group attended (including two
from WOC) familiar with the complexity of Major Trauma and the process of
training, where no formal scheme exists. Raw statistics paint a bleak picture of
inadequate preparation, for the sort of catastrophe which, by definition, comes “out
of the blue”. Surgeons cannot, like Life Savers on Bondi beach, sit idly waiting for
an emergency. Nor can every injury be sent to a centre of “absolute excellence” in
Trauma. Limb injuries will always be at the core of practice for every orthopaedic
surgeon. Major Trauma is more the business of intensive care physiologists, but
with specialists close at hand, to attend to the head and neck and chest, abdomen
and pelvis, all working simultaneously, not in sequence.
The stages of management of the severely injured can be divided according to
“Time” – taken to get the casualty to hospital (a s a p), to make the detailed
multiple diagnosis, sought on the basis of urgency, and requiring many “second
looks”. This has been established through the Acute Trauma Life Support protocol,
based on the “Golden Hour” after injury. ATLS requires attention to the vital
systems, respiration and circulation, followed by the second phases of renal,
neurological and skeletal function. These skills, like any other, depend upon
constant use, in order to maintain efficiency and excellence. Major Trauma units
are essential for the concentration of staff and equipment. They must not be
blocked by the minor and uncomplicated. In short the efficiency of the system
depends on expertise at every stage, from first aid to intensive care.
From profound experience Surgeon Commander Mansoor Khan, described his
training for his present post as designated “Trauma Consultant Surgeon,” at St
Mary’s Hospital, Paddington. This is one of four such units in London. He drew the
distinction between “ordinary general surgery”, and his responsible post as “Expert
in every department” ! The four faculty members spoke about their own training
and research, covering aspects from skin cover to the immune system. Mansoor
speaks with passion about his chosen practice, copying his role model Mr David
Nott. Mansoor stated that Nott has greater experience, probably, than any one
else in the world of Trauma. This he acquired by making himself instantly available,
even actively seeking catastrophes, through the Red Cross, MSF &c, far beyond
the boundaries of Orthopaedics!
Major James Barry showed his own experience in Iraq where six trauma teams
staffed six complete surgical “tables” in a huge hanger-like space in Camp Bastion.
The case is well made for Military Organisation. But the question remains -- such
high pressure is intermittent; and an idle, peacetime army can sag, without
dramatic activity.
Dr Hew Torrence, a research fellow of the College, drew attention to the unseen
impact on the immune system and the propensity for infection, which, not
infrequently, spoils a triumphant recovery. His title – “When the Bleeding Stops. . .”
- covered the sequence of steps toward reconstruction.
Dr Seema Valamanchilli gave a clear portrayal of her experience as one “in
training” for this non-specialist speciality. From these few succinct presentations
the difficulty emerges, of providing supervised instruction and at the same time, a
substantial work load. Also it underlines the importance of concentrating the most
widely injured casualties into dedicated units.
Questions were raised about the structure of tuition, relevant training and the
“road-side” immediate involvement of the totally uninformed and inexperienced
bystander – the immediate saver of life!
Pre-hospital care is often heroic; its
origin can only be in elementary education and community attitudes, conveyed
from ambulance men, first-aiders, community conscious personnel and sportsclub participants. In short the character and identity of a community, lies deep in
Samaritan neighbourliness. What is natural for every parent, should be part of
every citizen’s schooling.
Further questions related to the long term reconstruction (surely orthopaedic) to
restore the Casualty’s work potential. This is far removed from Trauma, but very
much the business of our specialty.
The College of Surgeons, is to be congratulated in taking this lead in the field of
Traumatology, while acknowledging the fact that “in Service Training” has not (and
perhaps can not) be neatly structured. In the search for the case-load experience,
the Trainee must be both immediately available, be able to travel at once and to
have instructional supervision. Indeed a very tall order; with a nod towards the
College’s Educational Course on Surgery in “Austere Environments”. Let it not be
forgotten, that the dangerously sick casualty has need for a broader experience of
surgery in general, than any special expertise. Indeed there is a hundred-fold
more victims of accidents in the world, than have need an arthroscope. The
grossly overloaded hospitals of the world’s LMICs are best able to provide
experience, hardly to be found in the West.!
The above report is a personal one, by no means comprehensive, nor
commissioned. (Ed)
-o0o-
Unconnected Correspondence:- “It is an uncomfortable fact that the
‘Western Press’ pays more attention to ‘tragedies’ affecting western (British)
people than others! What annoys me is that they report the ‘incident’ as though
there ought to be immediate ‘western’ emergency medical services available at a
moment’s notice’ everywhere – and are almost ‘critical’ because ‘our people’ were
not treated with the same efficiency as the troops in Afghanistan! And they always
concentrate on the ‘failings’ rather than the excellent work done by the ‘helpers’!
Is there not a place for wider publicity (broadcast media please note) of the ‘gap’
between the medical services (particularly for trauma) in so many parts around the
world – and the work WOC does in support.” (M. Morrison)
It is a curious feature writing these notes, that as one ages, and ceases to take an
active part in traumatology, one finds oneself reaching back towards the classic,
basic and simple, but still the most dramatically rewarding. The technical
problems of metal implants and tools, slip back towards truths and absolutes,
rather than to invented perfection. Much along these lines will comprise the WOC
session at the SICOT Annual Conference in Guangzhou (old Canton) in
September 16-19th 2015, incl. Fuller program details in the next Newsletter.
In the course of correspondence and conversation about the supply of basic sets
of surgical instruments for fracture management, Laurence Wicks has identified
the best prices and supply, from Tim Beacon, of Med-Aid international.
<medaidint@aol.com>
(M. L.)