The Appraisal and Management of Patients with Multiple Injuries

The Appraisal and Management of Patients with Multiple Injuries ROBERT H. KENNEDY, M.D., F.A.C.S. *

SINCE the beginning of this century, advances made in the treatment of all ills of the human race have been almost unbelievable. The rise of specialism has aided progress, but with doctors learning more and more about less and less. Meanwhile one large field remains woefully behind the general progress-the care of the injured. The need for proper care constantly increases in this machine age. It is estimated! that there were 9,500,000 accidental injuries in this country in 1957, with 95,000 deaths. Some of the injured are dead before help can arrive but many of the deaths occur after the victims reach the hospital. Not all are necessary. In this volume the care of various specific injuries is discussed. Many types are handled commonly only by specialists in certain fields. With increasing frequency we are confronted with persons injured in two or more sites and possibly affected in two or more body systems. The immediate problem is then saving life, to be followed after first aid by determination of the order of care of the various injuries in such a way that first things are done first. This can be accomplished only by organization, planned beforehand so that it can swing into prompt action whenever required. Each member of the hospital staff, professional or lay, is actually or potentially a member of the team. The important factor in this organization is the team captain. In a large hospital this should be preferably a general surgeon, not a specialist. In a smaller community hospital it might well be a general practitioner. The function of the team captain is to take complete charge of this multiple injury patient. He should call on whatever specialists are required, but the treatment which they recommend should not be instituted until the captain orders it at a time when he believes that the patient can stand it and when it is the most indicated next move. In order to save this life it is the team captain's duty to remain with this patient constantly for as From the Department of Surgery, Beekman-Downtown Hospital, New York, N.Y.

* Formerly Professor of Clinical Surgery, N ew York University Post-Graduate Medical School; Consulting Surgeon, Bellevue, University and Beekman-Downtown Hospitals. 1661

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many hours as are required, giving all the orders, seeing all the x-rays and laboratory reports, discussing viewpoints with the specialists, changing the order of procedures as changing conditions require. This one man must accept the responsibility for the life of this patient. It is no place for two attending physicians or an attending physician and a resident to be both ordering, possibly at cross purposes, or for a change in the condition of the patient to be allowed to occur without the immediate knowledge of the team captain. Telephone consultations will not suffice here. There are no statistics which show the number or percentage of multiple injuries, but the impression is that these are becoming more common. In the investigation" of automotive crash injuries at Cornell University Medical College, an analysis of 1000 injury-producing accidents in which 1678 occupants were injured has been made. "Multiple injuries constitute the most common pattern; actually over 66 per cent of all injured persons suffered injuries in two or more body areas." The automobile seems to be the most frequent agent in multiple injuries, but the plane, the train, tornadoes, hurricanes, explosions, ski accidents, falls, etc. all play their parts. All ages and both sexes are affected. Accident prevention is important, but multiple injuries will occur in spite of it. Two world wars have resulted in an unparalleled opportunity for great numbers of doctors to learn and practice the best methods. On return to civilian life after both wars, many doctors seem to have promptly lost their interest in trauma and the first principles of its management. It is not a/specialty and it should not be, since it cuts across all parts of the human body and no one can be as well trained as that. Knowledge of methods of treatment and laboratory control has been improved so that persons with severe injury can sometimes be saved who would formerly have died. The human being cannot stand unlimited trauma. With the extensively injured, no rules can be laid down to cover all cases, but there are certain principles to guide us, thereby not adding surgical trauma until it can be tolerated and not delaying reparative surgery until the progress of infection becomes more than the body can cope with. FIRST AID AND TRANSPORTATION

Two hundred thousand practicing physicians will not be the first attendants for the ten million injured people at the site where the accident occurs. Therefore we should urge all laymen to obtain basic training in first aid care. The patient needs immediately to have an open airway, hemorrhage stopped and shock arrested. Two or three minutes is about the limit before anoxia of the brain due to a plugged airway will produce permanent brain damage or death. One can practically never expect a doctor to arrive within two minutes. Therefore all laymen must know that an open airway must be restored immediately by turning a patient on the side if mouth and nose may be filled with blood, mucus or vomitus, by pulling the lower jaw forward if it has been pushed back by frac-

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ture, by pulling the tongue forward if this has slipped back and is plugging the pharynx. Administration of oxygen as soon as it is available is to be advised. We cannot object that the layman may create further damage, for death will be the result if immediate intervention is not instituted and the chance for life has thereby been lost. Noone likes to see the flow of blood so why not stop it. A layman can be trained easily to apply pressure to the site of external bleeding and to continue this pressure with something wrapped around a part. Pressure points are usually a delusion. Hemostats are not necessary. But life-saving blood is lost and shock is increased unless the first person seeing an accident applies pressure to the bleeding points. Tourniquets are to be condemned for use at the scene of accident, either by doctor or laymen, in almost all instances. Fractures should be "splinted where they lie" before any moving or transportation, or shock will be increased and greater local trauma occur from churning bones. The American Red Cross, the Boy Scouts of America, industrial first aid training and similar programs must all be supported enthusiastically by the medical profession if we hope to save the patient with multiple injuries. Speed in getting an injured person to a hospital by car or ambulance has practically never been the means of saving a life. On the other hand, such speed has frequently resulted in much more serious accidents to others than the one who is being moved. There is no reason for any ambulance driver not to live up to the local traffic regulations plus a siren. Competent first aid to create an open airway, to stop hemorrhage, to prevent the increase of shock and further damage to the soft parts from broken bones before moving the patient are what counts to save life. Therefore it is our responsibility to know that all ambulance drivers and attendants are well trained in first aid and that they are supplied with the necessary equipment to carry this out. Such supervision is lacking in most communities. What is the situation in your own town? RESUSCITATIVE MEASURES

The injured has now reached a doctor's office or an emergency room. The care of asphyxia, shock and hemorrhage, if they exist, takes precedence over everything else. If the patient is cyanotic or breathing with difficulty, we must make certain that he has an open airway, not filled with blood and mucus. Blood transfusion will do little good if the lungs are physically prevented by obstruction from receiving the oxygen to aerate the blood. Brain centers will not function long if aerated blood is not reaching them. If pharynx and trachea continue to fill with blood and fluid in spite of suction, tracheostomy may be the conservative procedure. A catheter inserted through a tracheostomy tube is frequently a more comfortable and less traumatizing procedure than a metal suction tip rammed against the back of the pharynx or the epiglottis. It also assures an open airway, unless the bleeding is beyond the main bronchi.

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A tracheostomy is life-saving in some brain injuries with perisiting mucus in the airway. If not in shock, the patient probably will be in a short time. Do not wait for the blood pressure to fall before instituting shock treatment as this is a sign that shock is already far advanced. Give morphine to relieve pain, except in brain injuries, and give enough to relieve it. Often absorption is poor and the dose may preferably be given intravenously. But don't give morphine, except as indicated for pain. If the patient is cold, warm him up and keep him warm, but this does not mean piling on hot water bags and blankets until he is bathed in sweat and losing precious fluid. He needs a transfusion. Obtain the blood for typing, Rh factor and crossmatching at the earliest moment, but have plasma expanders running until the proper blood is available. This will help prevent or relieve shock and will not waste time getting a needle into a vein when blood is ready. In spite of all our efforts, plasma is still far from safe as regards hepatitis. Unless one feels reasonably certain of the particular plasma one has, a substitute is preferable. Dextran is effective and has been improved so that allergic reactions are much lessfrequent. Polyvinylpyrrolidone (PVP) shows extensive retention in the tissues for at least 100 days. For the past ten years at Beekman-Downtown Hospital we have used Knox Special Gelatin Solution, Intravenous 6 per cent, entirely as plasma expander. We have found it satisfactory in its effect and without reaction. There are. still far too many cases of hepatitis resulting from single or multiple whole blood transfusions. Remember that whole blood is the fluid really needed in traumatic shock, whether there has been evidence of loss of blood or not. When there has been large loss of blood, be prepared for bulk intravenous transfusions into all four extremities if required. Glucose in saline or water is in general useless or worse than useless in these cases. Administration of too much fluid can be as dangerous as too little. Frequent checking of the specific gravity of the blood or the hematocrit is needed to furnish the right amount. Blood volume determination is all-important, but is not as yet usually practicable as a guide in moment-to-moment care. Hemorrhage must be stopped. Proper pressure application is almost always sufficient for external bleeding. Preventing further bleeding is nearly as important as replacing the blood lost already. Remember that one's own blood is of more value than that from any donor. Symptoms of hemorrhage without external evidence of it may require the finest in surgical diagnosis and judgment. Asphyxia, shock and hemorrhage must be considered first. Further treatment cannot be rendered except on a live patient. APPRAISAL OF THE PATIENT AND HIS INJURIES

We are presented with a patient with a definite serious injury which demands our attention. Is this the only injury he has, or even the most

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important one? A few minutes spent in trying to learn the mechanism of accident may save the patient's life. A fall in an elevator may result in fractures of the os calcis, above ankle or at knee, the vertebral bodies or base of skull, or any or all combined. The os calcis fracture is evident, but to disregard the other possibilities may mean that a simple compression fracture of the lumbar spine will produce a cord injury, possibly irreparable, in moving the person to or about the hospital. If the mechanism of accident has been such that severe injuries may have been produced, treat this patient as though these injuries have occurred. Suppose a person's trunk has been caught between the rear end of a truck and a wall, or by a rock fall in a tunnel or mine. He is dazed but not in too bad shape. Ribs may have been broken, puncturing pleura and lung, intercostal vessels may be bleeding internally, anything may have happened within or surrounding the abdominal cavity, including spinal injury. There may be little sign of anything definite when first seen, but the mechanism of injury has been such that it would seem that severe injury should have resulted. Handle him as if this is the case until all severe injuries can be ruled out by various tests at a time when he is able to stand them. Protect the patient from all further trauma until possible injuries have been disproved rather than consider that he was fortunate not to have been hurt more seriously. If a history is obtainable from the patient or a bystander, taking this history may mean using a few moments which will save life. Also remember that, while stories of sudden occurrences may often vary greatly, still they may give an idea of what happened. Next or simultaneously insofar as possible is the physical examination. The method of exa.mining the extensively injured is of great importance to him. It must be gentle and without undue exposure in order not to increase shock. Which are the immediately important fractures? Is there a possible abdominal or chest injury? With signs of possible abdominal injury we must consider the solid organs, liver and spleen, the hollow viscera with possible perforation, the blood vessels, e.g., mesenteric, the retroperitoneal organs-kidneys, adrenals, retroperitoneal hematoma, spine and spinal cord, perforation of the diaphragm, etc. We must decide whether any operative procedure is indicated to be done. at the first possible moment, which part of the body will be approached first when the condition improves sufficiently to do anything, whether no marked improvement can be expected in the general condition until some intervention has been accomplished even if the person dies in the attempt. These decisions may need to be changed as the condition changes, but we must constantly keep in mind doing first things first. There is no use applying skeletal traction suspension when we believe the abdomen must be explored at the earliest possible moment, requiring the taking down of the traction apparatus. Rather keep the

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part in emergency traction until decision is made regarding the abdominal trauma. X-ray examination is often carried to a ridiculous extent. What films do you absolutely need to determine what you will do to the patient first when possible and what will prevent further injury in the meantime? Demonstration of free air below the diaphragm may prove rupture of a hollow viscus. Examination for this is commonly done only in the upright position. The presence of a vertebral column injury may need to be proved before the patient can be supported in the sitting position without danger of spinal cord damage. However, the use of an x-ray tilt table allows the examination for free air without endangering the spinal cord. Too many early x-rays of the skull are taken. Unless the patient is cooperative enough to keep his head quiet, these should be postponed unless one believes they are absolutely needed to determine the presence of an' open depressed fracture or a fracture at a site which could readily produce an injury to the middle meningeal artery. Otherwise no operative intervention on the skull is going to be instituted early anyway, and x-rays for the record may be taken with better results later. The presence of fractured ribs proved by x-ray will usually make little difference in early operative treatment. There may have to be treatment for pain on breathing, for tamponade of the lungs with blood, for paradoxical respiration or tension pneumothorax, but time and effort spent on x-ray of the chest offer little in the early care of the extensively injured that cannot be learned equally well or better by the physical examination. Anesthetizing the proper intercostal nerves may often change the picture entirely in a patient suffering severe chest pain and difficult respiration. The blood must be kept oxygenated; adhesive strapping of the chest interferes with this. Beds in the admission ward are a practical necessity in these cases. Close supervision is necessary. For an orderly to undress a patient behind a screen often constitutes an acute danger. It is rbetter to cut .off a good shoe than to make a closed fracture of the leg an open ·one by-attempts to pull off the shoe. Coats and pants are much better cut for removal if movement might in any way endanger the patient. Critical time.is lost in moving to a ward, etc., which should be employed in getting plasma expanders and blood into a vein. Do not be satisfied with ordering fluids but know that they are commenced immediately. Upon the patient's arrival at the emergency room of a hospital an intern or junior resident is likely to be the first one to see him. We must see to.it that.he is made aware of the problem of the possibilities of.multiple injuries, particularly in the presence of one obvious complaint. Our organization should be such that the patient is not moved from ambulance stretcher to examining table to hospital stretcher to x-ray table, to stretcher to bed or operating table. From the time he is placed on a stretcher at the scene of the accident he should remain on the same litter

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Management of Patients with Multiple Injuries

until he is placed on the operating table or his own bed, without having shock, hemorrhage and soft part injury increased at each move. If a rapid check shows the possibility of multiple injuries, the proper member of the attending staff should be called in immediately. He then becomes the team captain in entire charge. As I have stated, in a large hospital this should be a general surgeon, not a specialist. In a smaller community hospital it might well be a general practitioner. The function of the team captain is to take complete charge of this multiple injury patient. DEFINITIVE MANAGEMENT

With fluid running and the advisable amount of preliminary examination completed, orders must be written so that assistants may be certain of the sequence in which they are to carry out examinations and treatments. If no traction was applied before the patient was brought to the hospital, naturally fractures requiring immobilization in emergency traction should have this done before plaster immobilization is applied to other fractures. If the team captain wants the pulse and blood pressure recorded every 15 minutes or half hour, he must see that someone is delegated to do this without making a doctor temporarily discontinue a more specialized part of the treatment. In the case of an unconscious patient does your order for a urine specimen mean when he becomes

MULTIPLE TISSUE TRAUMA

ASPHYXIA CRUSHED FOREARM AND HAND

SHOC/(

COMA FRACTURE OF F,EMUR

OPEN FRACTURE TIBIA AND fiBULA

HEMORRHAGE

Fig. 422. Multiple tissue trauma presents itself in shock, which is the chief physiologic disturbance. The essential problem, once all the sites of injury are recognized, is to determine the sequence of treatment. The orthopedist is the major consultant. The usual errors are insufficient treatment of shock, failure to recognize all the traumas, and mistakes in judgment, particularly the performance of prolonged complicated operations that could be reasonably postponed or simplified.

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TRUNK FRACTURES. GENITO-URINARY TRACT TRAUMA WIT·H ADDITIONAL INJURY CONCUSSION

OF BRAIN

ASPHYXIA FRACTURE

Of

CLAVICLE

vERTEBRAL FRACTURE

SlIfJfJK

RUPTURE OF BLADDER

COMA PELVIC

FRACTURE

HEMORRHAGE RACTURE

OF

FEMUR

Fig. 423. The presenting physiologic disturbance here is shock. The essential problem is recognition of the bladder injury. While the other traumas can be identified by ordinary roentgen means, the critical bladder injury can be easily overlooked. The techniques of urinary tract investigation following trauma have been systematized by Dr. Lazarus A. Orkin." The orthopedist is a close partner. He must defer treatment until the emergent urinary tract procedures have been performed. Following this, he must decide on his own regimen. The common error is to miss the bladder injury and perform extensive bone procedures.

conscious and voids voluntarily, attaching a container for involuntary voiding, or immediate catheterization to learn whether there is difficulty in passing a catheter into the bladder or if the urine contains blood or sugar? You examined the patient and your order must be framed so that your assistant has some idea of its immediate importance and what you are looking for. There is nothing rational in ordering for the extensively injured patient x-rays of all bones which your examination shows might possibly be fractured and not stating which, if any, must be done immediately to guide treatment at the moment. Do not expect the x-ray technician to read your mind or ask him to kill the patient by taking immediate pictures of most of the body. It must be your decision whether an x-ray finding may change the treatment in the next few hours for this critically injured person or whether he should be disturbed as little as possible. On the other hand, if x-rays of questionable injuries are not taken immediately, do not forget to watch for persistence of symptoms and to have these films taken later. An injury which at first seemed apparently minor may give the patient the most trouble afterward. Wounds should be cleansed, excised if indicated, and sutured as early as practical. Much loss of time and possible infection will be saved to the patient if he gets well, but this work must not endanger his life

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CENTRAL NERVOUS SYSTEM TRAUMA WITH

OBVIOUS ADDITIONAL INJURY FRACTURE OF SKULL LACERATION OF BRAIN

ASPHYXIA

FRACTURf OF RADIUS AND ULNA

OPERATIVE ""-+---'""-OF FEMUR

FRACTURE

SHDCK COMA

HEMORRHAGE

Fig. 424. The presenting physiologic disturbance in this type is a combination of shock and coma. The treatment of each should not interfere with the other. The presence of coma does not interdict necessary operation elsewhere as does shock. The chief consultant here is the neurosurgeon. It is important for him to cooperate with the team captain and orthopedist. Decisions as to nature and sequence of procedure must be jointly made. The common error is to place the patient on a neurosurgical service for an extended period of time with insufficient attention to the therapeutic requirements of the other injuries.

further by increasing shock or taking an assistant from more necessary procedures. .Hemorrhage must be stopped and an open chest wound closed immediately. Evidence of intra-abdominal perforation calls for operation as soon as the general condition is improved sufficiently to stand it. Otherwise there are few conditions that require operation until recovery from shock seems quite definite. With sufficient help in the form of operating teams and trained laboratory assistants to determine the need for and handle the introduction of fluids, operations can often be done much earlier, keeping shock under control during the procedures rather than knocking a person down again by operation as soon as he has recovered from shock the first time. In recent years the patient has been divided into compartments, sometimes anatomically and sometimes physiologically. This may be good in interval cases but is often tragic in the instance of multiple injuries. A directive exists in many hospitals that an x-ray diagnosis of fracture automatically admits the patient to an orthopedic bed. A fracture is about the only type of injury that will not kill the patient immediately. Consider a fracture of the pelvis. The bony injury will never be lethal but a rupture of the bladder, urethra or ileum may frequently result in

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CENTRAL NERVOUS SYSTEM TRAUMA WITH

HIDDEN ADDITIONAL INJURY ONCUSSION OF BRAIN

ASPHYXIA

EN

RUPTURED

SPLE

RUPTURED

KIDNEY

SHOCK

COMA (AMNESIA)

OPEN FRACTURE TIBI A INTO KNE E

Fig. 425. The presenting physiologic disturbance here is coma. This may be transient and thereby misleading since an accurate history is unobtainable and the physical signs of-bodily injuries blunted. Ultimately, the general surgeon carries the main responsibility. Shock due to internal hemorrhage may appear well after admission and the insidious nature of the clinical picture places a heavy burden on judgment as well as technical ability. The urologist and the orthopedist play important roles. The common error is to fail to recognize the severity of the intra-abdominal and retroperitoneal traumas.

death if unrecognized for a few hours. In some hospitals it is routine for all patients with rib fractures to be admitted to the orthopedic service. Fractures of the eleventh and twelfth ribs .on the left side will all too frequently have in addition a rupture of the spleen or the kidney. This is not an orthopedic problem. With fractures of the ribs at a higher level the orthopedist would be the first to admit that. his special training .did. not include the emergency. handling of tension pneumothorax or paradoxical respiration. The orthopedist should not allow the responsibility. for these types of cases to be placed on him. In other hospitals, any unconscious person is admitted to the neurosurgical service. This is a still more dangerous situation than that mentioned above, for this patient cannot even tell you that his chest, back or abdomen hurts and one has to be much more alert to make a diagnosis in these fields. Further, the percentage of head cases in which an immediate operation on the skull is indicated or will save the patient'slife is extremely small, but if there is an abdominalinjury .inthesamecase, timing of operation is all-important and' life-saving.'•. In .addition, there are still neurosurgeons who advise against any operative procedure in other parts' of the body until consciousness has been regained. If an

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EMBARRASSMENT OF RESPIRATION OTHER TRAUMA

MULTIPLE RIB FRACTURES WITH LACERATION OF LUNG TRAPDOOR PNEUMOTHORAX

ASPHYXIA

SHOCK DIVIDED

FLEXOR

TENDONS

COMA OPEN FRACTURE OF FEMUR

HEMORRHA"GE

Fig. 426. The presenting physiologic disturbance here is asphyxia. If severe, this can be rapidly lethal. The treatment begins at the site of accident with the removal of obvious obstructions in the mouth or pharynx, and the administration of oxygen, and continues as the team captain and thoracic surgeon take over. All other injuries are distinctly secondary in importance, As soon as the respiratory state is satisfactory, the other traumas can be treated according to the usual principles. The common error is to allow prolongedcyanosis to continue and to embark upon skeletal operations before a satisfactory cardiorespiratory state has been achieved.

abdominal exploration is indicated and the patient is not in shock, I know no better time to proceed than while he is still unconscious. For all these reasons the team captain should be the general surgeon or a general practitioner with the widest experience. He must consider the whole man and the whole problem from the first. No specialist can avoid being particularly interested in the problem in his own field. At the same time, the team captain must have the services of indicated specialists when he wants them, not tomorrow morning. He needs to discuss the case with them and not depend on their written notes composed possibly withinadequate knowledge of the entire problem. When operative intervention, further tests, etc. are advised by the specialist, permission for these must be given by the team captain at a time he decides on. An advised operation may be required, but it may well be the third or fourth procedure to be done once the injured person can stand any surgical procedure. The captain must have the veto power and the guts to use it. Laboratory services must be available. This particular injured person may "not be saved if 9 A.M. to 5 P.M. is the only time you can obtain experienced clinical laboratory or x-ray services. You are aware that there are more deaths every year in this country from blood transfusion than from appendicitis. Are you willing that the new intern on your staff, who

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RUPTURED ABDOMINAL VISCUS WITH

ADDITIONAL INJURY CONCUSSION (MILO)

ASPHYXIA RUPTURE OF JEJUNUM CONTUSION

OF BLADDER

SNlJfJlt

RACTURE OF CARPAL NAVICULAR FRACTURE OF PELVIS WITH TELESCOPING OF FEMUR INTO ACETABULUM

COMA

HEMORRHAGE BILATERAL OS CALC I S FRACTURES

Fig. 427. The presenting physiologic disturbance here "is shock. The chief problem is the decision for abdominal exploration in the presence of other obvious severe traumas. A mild concussion serves to complicate matters. In a vigorous patient, laparotomy is indicated if the possibility of a ruptured viscus exists. In older and severely shocked patients, the surgeon's judgment is tested to the full. Abdominal roentgenograms and abdominal puncture are helpful. A laparotomy with negative findings is a preferable error to belated repair or removal of a ruptured viscus. In this type, the orthopedist's role is secondary to that of the general surgeon.

has never done a blood typing or crossmatching before, shall be the one to decide at three in the morning that the blood he has in a bottle is all right to pump into the patient? Are you going to dowithoutanintravenouspyelogram and cystogram for possible ruptured kidney or bladder, orwillyou try to read an indifferent film taken by a surgical resident who has done his best to take a picture in spite of inadequate experience? I know no reason why pathologists or radiologists are more entitled than surgeons to forty hour weeks in the presence of multiple injuries. But you have to create the organization. Remember, it was routine for our young medical officers to save such cases in the latter part of World War II and in the Korean War. It is nearly as much of a routine to lose them today in civilian life. Good results are a matter of organization, preparedness and a triage officer in each individual hospital with authority. In definitive care, restoration of the cardiorespiratory physiology must come first, then treatment of injury to the hollow viscera-intestines, bladder and occasionally lung and heart. Care of liver, spleen and diaphragm accompanies these procedures when required. Open injuries of muscle and bone are next indicated to receive care. Usually closed fractures, head injuries and lacerations of soft parts can wait until their care can be tolerated after the above. But each should receive care at the

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earliest indicated moment as decided by the team captain. Later, any one of the injuries may become the only or major problem and the responsibility for the care of the patient should be turned over to whatever specialist is indicated. In 1951 Dr. Lester Blum, one of my associates, prepared a description and drawings of six general types of multiple injuries. We have used these in the succeeding years and found them instructive and comprehensive in considering these cases. I am presenting these drawings (Figs. 422 to 427) with description from his work, which was never published by him. Since the essence of treatment is organization, the classification of multiple injury patients into these several types is of distinct advantage. Each type is characterized by its own particular problems, although the general principles of treatment remain the same. In each, a different consultant plays a major role, but the team organization functions throughout. CONCLUSIONS

In many institutions today the patient with multiple injuries does not receive the best known care. The quality of first aid at site of the accident varies greatly. The emergency room is commonly not so organized that survey of the patient is accomplished promptly by a senior resident. Therefore, referral to an experienced member of the general surgical staff is often delayed so that valuable time is lost. Often specialists are called and each considers only the problem in his own field without sufficient coordination. Because of lack of authority given to one person, critical decisions may be delayed by useless bickering. The philosophy of a team captain to direct first things to be done first needs to be adopted by all of us if the patient with multiple injuries is to get a square deal in the use of known methods to save life and prevent permanent disability. REFERENCES 1. Accident Facts, 1958 Edition. National Safety Council, Chicago, Ill. 2. Braunstein, P. W., Moore, J. O. and Wade, P. A..: Preliminary Findings of the Effect of Automotive Safety Design of Injury Patterns. Surg., Gynec. & Obst, 105: 257-263 (Sept.) 1957. 3. Orkin, L. A.: The Diagnosis of Urological Trauma in the Presence of Other Injuries. S. CLIN. NORTH AMERICA 33: 1473-1495 (Oct.) 1953. 115 East 61st Street New York 21, New York