- Email: [email protected]
The Bradford accident service
I48
IYJURY:
THE
BRITISH
THE BRADFORD
JOURNAL.
Ot
ACCIDENT
ACCIDENT
SURGER1
SERVICE
A. NAYLOR Comrltant in Accident and Orthooaedic Surgery, Orthopaedic Hospital, Rawdon, ir. Leeds Bradford Royal Infirmary (540 beds) and Bradford St. Luke’s Hospital (720 beds) together with the Children’s Hospital (83 beds) are the major general hospitals serving an urban population of approximately 500,000. An orthopaedic department was opened in the two major hospitals in 1945 under one orthopaedic surgeon. There were 50 beds for mixed accident and orthopaedic cases in each unit and each had a casualty department, although the major casualty department was at the Bradford Royal Infirmary. A few beds were available for children in the Children’s Hospital where injured children were taken to a small receiving room. A second surgeon was appointed in 1946. In 1954 some concentration was possible by the improvement and conversion of a convalescent hospital on the outskirts of the city to become Woodlands Orthopaedic Hospital ( I I2 beds). The in-patient department of St. Luke’s was then closed and only outpatient clinics and a receiving room maintained there. All the major road accidents were then directed to the Royal Infirmary, but it soon became evident that it would be impossible to staff a casualty department adequately for 24 hours per day in three hospitals, each separated by one and a half miles. Thus, in June, 1960, the casualty departments at St. Luke’s Hospital and the Children’s Hospital were closed and the department at the Bradford Royal Infirmary was adapted to become the sole accident and emergency department for the hospital group serving the above population. This was effected after discussion with the local medical committee and subsequent newspaper advertisement and publicity. All trauma was then concentrated in the former orthopaedic wards of the Bradford Royal Infirmary (62 beds-31 for each sex) and non-traumatic orthopaedic conditions, including those of children, were dealt with at Woodlands Orthopaedic Hospital. The 62 beds are now utilized solely for trauma with the exception of burns, and injuries to the eye, ear, nose and throat. The last two groups have always been, and still are, treated exclusively in their respective departments and out-patient emergencies of these THE
Bradford Hospitals
ntld Woodlmcls
do not attend the accident and emergency departments. Burns, stab wounds, and gunshot wounds of chest and abdomen are admitted directly to the general surgical and thoracic surgical wards, but with these exceptions, all forms of trauma are admitted to the accident unit which, together with the accident and emergency department, is under the direct supervision of the consultant orthopaedic surgeons, the senior being the administrdtive head of the unit. Other specialists are called in on suspicion of such injury by the orthopaedic consultants, or in extreme emergency by registrars, to examine, advise on, and treat the injuries of their specialty, itr the unit. The accident and emergency department and the accident and orthopaedic service provided are staffed by three consultant orthopaedic surgeons. A fourth orthopaedic surgeon recently appointed will take LIP duties in the near future. The junior orthopaedic surgeon undertakes definitive sessions in the accident and emergency department in addition to his normal accident and orthopaedic duties. He holds a special clinic for all infected hands once a week and once a week he conducts an instruction and training session, which all accident officers must attend. For the smooth working of the department, each consultant orthopaedic surgeon will see each other’s patients as necessary, particularly in the early stages of treatment. No surgeon has any particular number of beds, the beds being available in the unit as required. The unit has the advantage that the accident and emergency department and the orthopaedic and fracture clinics are one selfcontained department of the hospital, thus ensuring that one unit is responsible for treating all types of injury, major and minor. We have changed the name of the fracture clinic to trauma clinic as both fractures and major soft-tissue injuries are seen here. It is so arranged that an orthopaedic consultant is in the department, either in the accident and emergency section or in the fracture or orthopaedic clinic every morning or afternoon of each weekday. Each orthopaedic surgeon is responsible for the same two admitting
Volume Number
3 3
ACCIDENT
SERVICES
days per week, for all attendances and admissions to the accident and emergency department and the accident wards. The additional medical staff are:1. A senior orthopaedic registrar who takes part in a rotation scheme of training with the two teaching units in the region. 2. Three accident and orthopaedic registrars, each working with one orthopaedic surgeon and responsible with him for the treatment of all accident and emergency attendances, accidents, and the non-traumatic patients in his charge and for those who attend on his admitting days. He also takes part in the treatment of the nontraumatic orthopaedic cases at the Woodlands Orthopaedic Hospital, the orthopaedic outpatients and fracture clinics, thus obtaining a complete training in all aspects of orthopaedic work. He is on call for the accident and emergency department while on duty for his chief’s admitting days. The junior registrar is one of four taking pan. in a two-year rotational Fellowship training programme, which consists of one year of general surgery, six months of thoracic surgery, and six months of accident and orthopaedic work. He usually works with the junior orthopaedic surgeon. 3. Junior sta$ Until a year ago there were five accident house officers (senior house officers) working in the accident and emergency department which is recognized for the F.R.C.S. Casualty requimments. This was increased to six earlier this year. In addition to work in the accident and emergency department, they partake in the work of the accident wards and attend at operations and fracture clinics, but they have no responsibility for the ‘cold’ orthopaedic clinics and patients. They attend a weekly teaching round, togethewith the ward rounds in the accident unit which are conducted by each of the consultants with their staff, in addition to visits whenever requred for an emergency and as necessary on their take-in days. There are normally 16 general practitioner clinical assistant sessions in the accident and emergency department. These cover every afternoon and some morning sessions. The aim is to provide three accident officers each morning, two in the afternoon and two each evening to I I p.m. From I I p.m. to 9 a.m. one accident officer is on duty. To allow the accident officers time for reading, instruction, anld attendance on their accident the afternoon sessions are covered wards, entirely by general practitioners. As an orthopaedic consultant is in the combined accident and emergency and orthopaedic department during
TODAY
149
this time, senior advice and help is readily available. The discrepancy between the number of junior hospital posts and the available doctors to fill them, partly due to the recent decline in the number of overseas graduates, has necessitated a change in the pattern of junior staffing. At present there are three accident officers who work part-time in the accident wards, the theatre, and the accident department, but the department is now staffed from 9 a.m. to 5 p.m. by increasing the general practitioner sessions, and some sessions in the evening are also covered by these doctors. Assistance after 5 p.m. until 9 a.m. next morning is now given by all grades of junior staff, including senior registrars who undertake these additional sessions with payment, and on a volunteer basis. 4. Nursing stafl The accident and emergency section has two experienced sisters in addition to the department sister, and there are four full-time and six part-time staff nurses, equivalent to seven staff nurses, and six nurses in training working in the department between 7.30 a.m. and 10 p.m. After IO p.m. there is one sister who can call additional auxiliary and pupil nurse help. Another sister with three part-time staff nurses and a ward orderly are responsible for the plaster room and orthopaedic and fracture clinics. Three full-time plaster orderlies are on duty from 9 a.m. to 6 p.m. to assist in the orthopaedic and fracture clinics and with the treatment of fresh accidents. Members of parachute regiments attend for instruction in the care of the injured. 5. Secretarial assistance. Adequate secretarial assistance is essential for the smooth running of an accident and orthopaedic unit. There are two full-time and two half-time departmental secretaries, one of the latter helping with clerical duties in the accident and emergency section. All notes of patients in the orthopaedic and trauma clinics and in the accident wards are typed and all documents and radiographs for current patients are filed in the department until the patient is discharged from the unit. Every patient attending the accident and emergency unit has a letter sent to his or her doctor. Initially these were typed, but in view of the varying number of the accident officers now working in the unit, a pro-forma letter written out by the accident officer at the time of the patient’s attendance has replaced the typed letter. We think it essential that every doctor should have a letter about his patient, the treatment which has been given, and what future treatment is contemplated. New and follow-up patients who attend the trauma and orthopaedic clinics are seen by
I 50
INJIJRY: I lit
hlJL,r\
BKITISH JOURNAL (II A(‘C1L)t.NI SI:RtiER\
appointment. In the accident and emergency section return visits are also by appointment, these being staged throughout the day from 9 a.m. until 6 p.m. and on Saturday mornings until I p.m. This reduces the risk of a large number of follow-up patients interfering with the reception and treatment of new patients, and is the only possible way of preventing the department from being over-run by large numbers of patients at any one time. The reception and records department is manned by clerical staff from 9 a.m. to 10 p.m. every day, including week-ends and holidays, but 24-hour cover is desirable as reception duty by nurses after the working hours of clerical staff, while possibly not arduous, is wasteful of valuable nursing staff. In the reception area there are voluntary receptionists who help to direct patients to the various sections of the unit, thus maintaining a smooth flow. One member of the hospital administrative staff is delegated to see that the administrative arrangements of the department run well. Direct telex links with the ambulance depots are maintained from the hospital. A room adjacent to theaccident department is set aside for the collection of all patients who have to be taken home by ambulance and in this room a member of the ambulance staff is in attendance to operate the telex system. Here arrangements are made for the subsequent collection of patients by ambulance for clinics of all types. There is no direct radio-telephone link between ambulance and emergency department, but there should be. Three operating sessions are held each week. Each consultant orthopaedic surgeon conducts an operating session together with his registrar and sometimes the senior registrar, for the nonurgent operations on trauma cases, two theatres being in full use during these sessions. In these sessions, operations for fractures of the neck of the femur, open reduction of fractures, together with nerve suture, tendon grafts, and bone grafts are undertaken. Minor cold orthopaedic operations for out-patients such as ganglia and nerve entrapment release are also undertaken on these lists. The more urgent cases needing operation are dealt with on the next available list, whichever surgeon is responsible for their care. Emergency cases can be dealt with readily in one of the main operating theatres, where the necessary staff is available. The stretcher reception room has six stretcher bays, each equipped for the resuscitation of any emergency, but unfortunately we have no space available for separate resuscitation facilities.
1972
.I,*n
The department has its own radiograph unit tiith apparatus capable of the radiography of all parts of the body and an automatic processing unit, a 24-hour radiographer service being provided. At busy times radiography for backache is undertaken in the main radiology department to relieve congestion in the accident unit. Dressing cubicles are available for both clean and ‘ dirty ’ dressings, it being important that these two divisions be separated, each having its own appointments system. The department has a ‘ clean ’ theatre where lacerations can be sutured and there is a * dirty. theatre for septic cases. To avoid cross-infection regular tests are made by the consulting pathologist responsible for the control of infection in the hospital. No ’ cold ’ minor operations are undertaken in the department, it being essential to reserve the theatres in the accident and emergency department solely for accident cases. Fractures are manipulated in the orthopaedic plaster room adjacent to the unit radiology department. TYPE
OF CASE SEEN IN THE ACCIDENT AND EMERGENCY SECTION
It is important from ambulance Tdh
/.-TYPE
ACCIDENT
to separate walking patients patients and, if possible, to OF NEW
CASE A-WENDING
THE
AND EMERGENCY DEPARTMENT
TYPF OF CASE
Non-emergencies (walked-in-referred back to doctor without treatment) Fractures Bone and joint injury (no fracture on radiograph) Lacerations, including muscle and tendon iniuries (hand iniuries included in the above three categories 13 per cent of these) Head injuries Chest injuries Sepsis in limbs, hands, and feet Perianal and breast infection Dog bites Burns and scalds Poisons and overdoses Medical Drunk Foreign bodies swallowed Abdominal emergencies on 999 calls Gynaecological (abortions, haemorrhage) Genito-urinary (retention) Dental E.N.T. (foreign bodies in nose) Miscellaneous (rings too tight, stings)
PERCENTAGE
2.2 14.3 37.3
22.0 3.0 0.15 3.7 0.15 1.9 4.4 3.0 2.0 0.15 0.9 0.3 0.3 0.15 0.9 0.15
1.o
Volume 3 Number 3
ACCIDENT
SERVICES
maintain two separate lines of patient flow. The aim is to confine attendances in the department strictly to accidents and emergencies. If other than these atter,d (which amount to 2.2 per cent of all cases) they are usually referred back to their doctor, or if the occasion seems fit, to the appropriate consultant’s clinic. If such a case is referred by a general practitioner to the accident
0 16
1
,,,,I 7 6 9 10 11 12 -8 -9 -10 -11 -12 -1
7 -8
F(g. 1.-Case
8 9 xl 11 12 -9 -a -11 -12 -1 A.M.
TODAY
151
included in those attending the major follow-up clinics which are held three times weekly at which a consultant is in attendance. Between 100 and 120 patients are seen at each of the major clinics. The remaining three trauma clinics are held by the orthopaedic registrar on call, the patients having appointments given to them on their first attendance at the accident and emergency
3 -4
L -5
5 -6
6 -7
7 -6
9 9 10 11 12 -9 -10 -11 -12 -1
1 -2
1 2 3 -2 -3 -I P M.
L -5
5 -6
6 -7
7 -6
8 9 10 11 12 -9 -10 -11 -12 -1
1 -2
1 -2
2 -3
load of attendances at accident and emergency department. (Reproduced by kind permission of the Editor of the ‘Journal of the Royal College of Surgeons of Edinburgh’.)
and emergency department, it is referred back to him with a polite note suggesting that he might care to send the patient to a consultant of his choice as the patient is not suffering from an emergency condition, and the accident and emergency department is not a consultative clinic. An urgent out-patient appointment can always be obtained by the practitioner by direct request to the appropriate consultant. Table I lists the different types of case attending the departmem, showing the preponderance of orthopaedic conditions. Attendances in the accident and emergency department progressively increased until 1967, since when they have remained steady at approximately 42,000 new attendances per year. Our aim is to minimize return visits to the department and to use this section as an initial treatment and sorting unit. Patients with fractures, joint injuries, or any patient who has had a plaster cast applied, must attend the trauma clinic next day, this being held every day except Sunday. These patients are
department. Subsequent attendances are distributed to the three major trauma clinics, patients being followed up by the consultant who was responsible for their care on their first attendance. A study of the times of appearance of new patients in the accident and emergency department is helpful in allotting medical and nursing staff to the department at different times of the day. Fig. 1 shows a steady rise in the number of patients attending between 8.30 a.m. and 10 a.m., followed by a steady fall until lunch time. A further small rise occurs between 1.30 p.m. and 3 p.m. when a rapid fall occurs with few attendances until a rise appears at 7 p.m. This is attributed to the accidents which have occurred towards the end of the working day and to those who have been referred by their family doctors. On Saturday a further small rise usually occurs between 10 p.m. and 11 p.m. Minimal staffing is One thus required between 4 p.m. and 6.30 p.m. medical officer is allocated to the reception of
152
INJURY:
THE
BRITISH
JOURNAL
walking patients while another undertakes duty in the stretcher reception room. Fractures are treated in the plaster room where a small recovery room is available. The patient is asked to read the printed pamphlet dealing with possible complications after fracture reduction and plaster application. This also tells him about necessary finger movements, with advice to return if any complications arise and what the signs of these are. An appointment for the next day’s trauma clinic is then given to him. Patients who can be appropriately treated by their general practitioner, works doctor, or works nurse for dressings or removal of sutures are referred back to them and no return appointment made. Table I shows that approximately 30 per cent of new attendances are for the treatment of lacerations, abrasions, and puncture-wounds. Fifty per cent of attendances are for joint and limb injuries or for the exclusion of bony injuries and of these about 14 per cent prove to have fractures. The importance of tendon, joint, and closed soft-tissue injury in the absence of a fracture is constantly stressed to the departmental staff. Eye and ear, nose, and throat emergencies go directly to the out-patient department of those units. After 5 p.m. and until 9 a.m. they attend the accident and emergency department but are seen exclusively by the ophthalmic and E.N.T. staff and do not enter into the normal patient flow of the department. Two per cent of admissions are classified as medical emergencies who have been brought to the hospital directly without visiting their own doctor, while 2.5 per cent of the cases are those of poisoning and attempted suicide, adding up to a total of 4.5 per cent of admissions which are a medical responsibility. One consultant physician manages all cases of poisoning and after their initial examination subsequent treatment and admission are undertaken by his staff, and the accident and emergency department has no further responsibility. There has been an increase in medical emergencies over the past five years, largely because a coronary care unit is stationed in the Bradford Royal Infirmary and this serves the whole hospital group. If the admission of a medical emergency is necessary, a member of staff of the medical division is sent for and he has the responsibility for arranging admission and whatever treatment is necessary. As there is no separate provision for the examination and treatment of medical emergencies in the restricted space of the accident and emergency department, a time limit of about 20 minutes has had to be made, after which failure of the member of the
OF
ACCIDENT
SURtiERL
Jan.
InJury 1972
medical division to attend the case will result in the patient being admitted to their ward. It should be emphasized that the accident officer on duty has complete authority to admit any case to any department he considers necessary in emergency. All accident officers are given an instruction book containing a series of standing orders in the department, referring particularly to the disposal of cases, to the times of consultant orthopaedic and fracture clinics, and dealing with procedures to be undertaken in specific circumstances, e.g., where admission for social, rather than medical purposes is necessary, or where reference to other departments and consultant clinics may be required. The booklet also gives brief notes on the treatment of common conditions as indicated by the individual consultants, and particularly on which patients /trust be admitted, e.g., all children with supracondylar fractures and any patient who gives any history of unconsciousness, however momentary, following a head injury. The book also contains a scheme of wound treatment, antibiotic therapy, No anti-tetanic and anti-tetanus treatment. serum is used in the department, it being the practice of the unit to give tetanus toxoid together with an antibiotic for prophylaxis, this being combined with adequate wound cleansing or excision as indicated. Cases of burns which can be treated as outpatients are seen at a weekly burns clinic held by the plastic surgery department, in the accident and emergency unit. The use of inflatable plastic splints for temporary splintageof limbs, while awaiting radiography or attention to their fractures, has proved invaluable. ADMISSIONS
TO THE
ACCIDENT
UNIT
Patients needing admission are moved to the accident ward under the care of the orthopaedic surgeon of the day, who assumes responsibility throughout for the whole patient and co-ordinates the activities of the other consultants taking part in his treatment. In the ward a further examination is made, the orthopaedic registrar on duty being called to every admission. When the orthopaedic injury is combined with injuries to other systems the appropriate specialist is summoned by the orthopaedic consultant or, in emergencies, by his registrar. A general surgeon is summoned for abdominal injuries, the thoracic surgeon for major chest injuries, and the urologist for injuries of the genito-urinary system.
Volume 3 Number 3
ACCIDENT
153
SERVICES TODAY
Head injuries are under the care of the orthopaedic surgeon scting under the supervision of a visiting neurosurgeon. The latter visits the unit once weekly and on request in a specific emergency. Any cases requiring expert neurosurgical attention are transferred to the unit at Chapel Allerton Neurosurgical Centre, Leeds, IO miles distant, but in an extreme emergency a burr-hole and initial neurosurgical treatment can be instituted in the accident unit by the orthopaedic staff, a sterile naurosurgical instrument set being kept in readiness at all times. Patients with burns are admitted to the care of the general surgeon of the day, but patients with burns of the hands and face are transferred to the plastic surgical department; major burns are transferred to the Regional Burns Unit at Pinderfields Hospital, 16 miles distant, but only after resuscitation has been begun. The majority of admissions to the accident ward are those of injuries to limbs (70 per cent). Many are assoc ated with head injuries of varying severity, but about one-third of admissions are for the observation of head injuries alone. A special system of recording the clinical and neurological stete of such a patient is instituted immediately he arrives in the accident and emergency department and continues throughout his stay in the accident ward, where half-hourly records of pupils, pulse, blood-pressure, temperature, and conscious state are maintained. An intensive care unit headed by a consultant anaesthetist provides four beds where severe multiple or hlzad injuries, particularly those needing ventilation, are admitted, but they are transferred to the accident unit as soon as feasible. While the responsibility for the patient rests with the orthopaedic surgeon, the anaesthetist decides on the timing of this transfer. The number of admissions to the unit showed a rise from 2050 in 1961 to 2600 in 1964-5 and the early part of 1966. The projection of this curve at that time showed that the number of cases likely to require admission would be in the region of 2700. This has been shown to be correct and the admissions in 1970 showed a slight increase on these estimates. To accommodate this increase, we have successfully reduced the bed occupancy from 9.37 days per patient to 7.72, but it is evident that the unit is becoming too small both to dl:al with the number of in-patients and out-patien1.s attending the department. On numerous occasions the accident unit is filled to overflowing and patients from the unit have to be ’ slept out ’ in other wards to accommodate the new admissions. The promised new unit of
100 beds with a neurosurgical department and associated staff, new out-patient department and wards has still not yet reached the planning stage. Twenty-eight per cent of admissions are female, of which many are suffering from fractures of the femoral neck, while 58 per cent of admissions are males. Of those patients admitted, 14 per cent have been children. They are detained in hospital for the immediate acute phase, those requiring further hospital stay being transferred to Woodlands Orthopaedic Hospital to continue their treatment there. The majority of children, however, are admitted for observation of relatively minor head injuries and they stay in hospital for two or three days only. ANALYSIS
OF CASES
ADMITTED
The ratio of severe to mild head injuries is approximately I : 6 in males and still fewer in females. Limb injuries, e.g., fractures of long bones, are often multiple, and make up 65-70 per cent of the admissions. Any discussion on accident units, and pariicularly their staffing, is usually highly coloured by reference to the treatment of multiple injuries. These, of course, are very dramatic and serious and do require highly trained experienced staff available at all times of the day and night. Any accurate assessment of the problem is difficult when one tries to define what is included in the ’ multiple injury ‘. The Platt Report category stated that an average of 2 per cent of admissions consist of multiple injuries. Our own figures, based on a definition of a head (and/or chest) and two or more major limb injuries, show that approximately 5 per cent of admissions have severe multiple injuries, but these figures are likely to vary with the proximity of the hospital to a motorway, where injuries to more than one system are likely to be more frequent. I feel, however, it should be emphasized that in an average large industrial town such as Bradford (and the majority of hospitals are not near motorways), one must budget for the treatment of the far more numerous and less sensational limb injuries, but must, in addition, be able to deal with the more complex multiple injuries at the same time. The organization should undertake the treatment of all types of injury, major or minor, and thus the accident and emergency department should not have a separate staff or head of department. The entire accident service should be one functional, geographical, and organizational entity, staffed throughout by the same surgeons. No single specialist (e.g., an ‘ accident surgeon ‘) can be sufficiently experienced and expert in all
154
INJURY
: I’HE
BRITISH
JOURNAL
special branches of surgery with their increasing complexity to deal with all, and therefore teams of consultants in all specialties have to be available to deal with the different aspects of multiple injuries, the orthopaedic surgeon acting as co-ordinator while dealing with his particular aspect. Thus the expert should be available initially, where his special experience is so essential and not engage in treatment at ’ second hand ‘. Abdominal
Injuries
The rarity of abdominal injuries in civilian practice is noteworthy. In our unit they form no more than 0.2-0.4 per cent of the total injuries, i.e., only 4-6 patients per year, out of a total of 2500-2700 admissions, require laparotomy. Genito-urinary injuries have a similar incidence. This approximates to the figures published in a ten-year series in Leeds (Wilson, 1963) where only I in 914 accident admissions (0.1 per cent) had an abdominal injury. This infrequency reinforces the argument that such injuries should be dealt with by the duty general surgeon who is dealing daily with abdominal conditions, rather than by an accident surgeon who might have to open the abdomen on the few occasions demonstrated by these figures. Thoracic
Injuries
Chest injuries requiring a thoracic surgical procedure form 0.5-0.8 per cent of admissions to the unit, but the frequent association of thoracic and upper abdominal injury is constantly stressed to the junior staff in the accident and emergency department. Our thoracic surgical colleagues are frequently consulted on the management of respiratory problems of patients admitted to the accident unit, even though the chest injury may be apparently minor. In recent years, direct injuries to the thorax, involving stab and gunshot wounds, have unfortunately been increasing and between 1961 and 1965, I6 stab and 3 gunshot wounds of chest were admitted directly to the thoracic surgical department. Plastic Surgery Maxillofacial injuries and problems of skin loss and replacement are treated by our plastic and oral surgeons. Head Injuries Approximately 40 patients per year are transferred to the neurosurgical centre in Chapel Allerton, Leeds. Head injuries carry a high mortality ranging from 15 per cent in the O-15
(II-
ACClDtN
I
SIJRGtRY
age-group and 24 group, while it rose the age of 60, and cent of the patients Fractures
IilJUr} .Irlll.
1972
per cent in the 15-60 ageto 60 per cent in patients over these latter comprise IO per transferred.
of the Neck of the Femur
Many patients with fractures of the neck of the femur are admitted, most of them being female. In 1961 there were 271 such admissions, amounting to 5 per cent of the total admissions to the unit and threequarters of them were female. This number has reduced recently over the past 7 years because of the opening of additional units in the area formerly drained by this hospital, but we still admit 190-200 fractures of the neck of the femur each year. The majority are treated by some operative method, which requires considerable theatre time and staff. An active geriatric service working in close association with the orthopaedic department has allowed the early removal of patients with social problems, and it is only by this means that so many patients can be accommodated in a unit of this size which deals with such a large total. Major Catastrophes
outside the Hospital
A plan has been evolved to deal with a major accident or catastrophe within the area served by the hospital, from which a team consisting of a surgeon, an anaesthetist, and two sisters, with special equipment in the accident and emergency department, is despatched to provide essential surgical treatment and resuscitation at the site of the incident. A rehearsal of this scheme is conducted at intervals in co-operation with police, fire, and ambulance services. Rehabilitation
Facilities
The accident unit is visited daily by one of the physiotherapy staff for group exercise therapy, with subsequent individual treatment. A large physiotherapy department supervised by an orthopaedic consultant is situated below the accident wards, near the accident and emergency and a school of physiotherapy department, attached to the hospital group and centred at the Bradford Royal Infirmary is provided with the opportunity to gain a large experience in the treatment of all forms of trauma, including the patients in the intensive care unit. Non-diversional occupational therapy is unfortunately available only at another hospital in the group. In-patient diversional therapy is available in the accident wards. The solitary social worker attached to the accident and orthopaedic unit is invaluable, but such a number is woefully
Volume 3 Number 3
ACCIDENT SERVICES TODAY
inadequate. Application to set up an industrial rehabilitation unit attached to the hospital has been made on .two occasions with scant success. It was intended that this unit should supplement the available facilities provided by the Department of Employment and Productivity, and would aim at providing a protected workshop with a view lo returning the patient to his normal pre-accident work, i.e., it would act as a ‘ toughening-up ’ centre, before return to full work. The initial approach was ignored completely by the Regional Board, Management Committee, and members of industry in the town. A subsequent approach, however, gained benevolent approval if the money could be raised outside the service, and approaches were made to local industry and to trade union representatives. The appalling lack of interest, however, was quickly evident, all relevant parties pointing out that there is little or no financial incentive for a patient to work. in a protected workshop until he became fit to take his normal place in his preaccident work. It is hoped that this type of rehabilitation facility will be provided in the new accident unit when it is built. CONCLUSIONS FROM OUR EXPERIENCE OF THE PAST TEN YEARS 1. The benefits of concentrating accident and emergencies in few centres has been evident. In the west of the Leeds Region, including the City of Leeds itself, there are now 8 centres dealing with a population of over 3 million. These centres each provide a 24-hour service and they demonstrate amply that much greater concentration along these lines could be undertaken in other areas in this country with advantage, with improvement in the services provided, and with some saving of manpower. 2. It is essential that an accident and emergency department should not act as a second general practitioner surgery. Publicity campaigns to the general practitioners via the local medical committee and to the general public via the press and mass media, have helped our department to put this into active practice and to maintain the department solely as an accident and emergency department. A.rrangements should be available for general practitioners to have their patients with urgent conditions seen at the next available clinic by direct application to the consultant. It is important that the accident and emergency department is not available as a second consultative clinic. 3. It is essential that the accident and emergency department and the orthopaedic out-
1.55
patient department should be physically and achitecturally one unit. This allows the constant presence of consultants and all grades of staff, who are then available at all times in the department, and can thus exercise a close supervisory and consultative role in addition to the active management of acute accident cases. This allows the accident officers to be constantly supervised and taught by their consultants. Further, it allows a fully integrated accident and orthopaedic service which, with the aid of their colleagues in other specialties, can deal with accidents of all severities from the mildest to the most severe cases of multiple injury. 4. The concentration of all injuries in accident wards from which all other types of patients are excluded is essential to a comprehensive accident service. These patients should be the responsibility of the same person who sees them and is responsible for them in the out-patient and accident and emergency departments, i.e., the same consultant who was on duty on the day they were admitted and who was responsible for all accidents and emergencies attending the accident and emergency department on that day. The unit must be within a general hospital, thus ensuring the availability of all specialties. Accident teams with a co-ordinator readily available are essential and preferable to the ‘jack of all trades ’ accident surgeon. Such a structure obviates the need for observation beds in the accident and emergency department itself. It is often maintained that observation beds in such a department are unsatisfactory because they are difficult to staff and to keep patients under constant observation. We agree with this. Any patient requiring such observation should be admitted to the accident ward where all facilities are available for investigation and treatment of any accident case. The suggested national average of 35 beds per 100,000 is too small. In general, these beds have been included in those of specialties, mixed with non-urgent cases. It is essential that separate allocation for accident cases should be made. 5. Our experience shows that it is important to maintain a constant check on the return visits to the accident and emergency department and on the type of patient attending for the first time, so that any adjustment to the organization necessitated by changed circumstances can readily be made. Thus, the surgeon in charge of the accident and emergency department and the accident services in the hospital group should have time set aside for this aspect of organization in the relevant departments. It is still evident that
156
INJURY:
THE
BRITISH
JOURNAL
in the large majority of hospitals, despite good organization, facilities are quite inadequate for the number and types of conditions requiring treatment. Regrettably, our own department has virtually no waiting space for patients. Our patients still have to sit around in corridors, obstructing the regular flow of others. 6. The accident and emergency and orthopaedic department should have its own separate radiograph department strategically sited to facilitate patient flow and minimize movement of patients being resuscitated. While we have such a department excellently sited, it has proved to be too small and we now have to plan for its expansion, even in the present limited space. The importance of a separate radiograph department set aside for the accident and emergency service is still not appreciated, as is evident in the development and planning of new hospitals without this facility despite the fact that the necessity for it has been well publicized. 7. A large number of stretcher cubicles for the reception of injuries and emergencies brought in by ambulance is essential. Most departments have totally inadequate facilities for this. Our present department requires at least double the amount of space for such patients. Resuscitation rooms separate from general reception cubicles are essential. 8. It is important that all specialties should be responsible for the primary treatment of their own out-patient emergencies and it is regrettable that this is not yet appreciated or accepted in many areas. Individual consultants must be responsible for the primary care of the emergencies in their own specialty and such responsibility cannot be delegated to one general factotum in the accident and emergency department. The Royal College of Physicians has now recognized the necessity for such responsibility for medical cases and has recommended that all accident and emergency departments should have a physician responsible for the organization and treatment of medical cases attending the department, a step we advocated a long time ago (Naylor, 1967). Such a subsection of the accident and emergency department would need to be staffed by one or more consultant physicians, possibly the consultant physician of the day and his team of registrar and house officers. From the number of patients attending, this physician would not need to be physically present in the department all the time when on duty, but could be undertaking some duties in the vicinity of the department and be readily available for consultation and for treating the patient.
OF
ACCIDENT
SURGERY
Jan.
Injury 1972
A simple appointments system prevents overcrowding of the department by return visits at any particular time, thus allowing freedom of manceuvre of the staff to attend to any new cases. 9. The difficulty of staffing an accident and emergency department with junior staff below registrar grade is becoming more acute, and is likely to prove a permanent feature until larger numbers of new medical graduates are available. The deployment of general practitioners in our accident and emergency department has proved of considerable advantage both to the department and to the practitioners themselves. It is our experience that this is a department in which general practitioners can employ their skill and experience to great advantage to the hospital service, and allow them to partake in interesting work amongst their specialist colleagues. It is essential that they be given contracts with security of tenure so that they can plan their regular attendance at the department. Training of more senior staff to work in the accident departments to support the accident teams, i.e., to deal with emergencies and sorting as opposed to accidents only, could well be the same as a vocational training for general practitioners. The combination of work in the accident wards and theatre with that in the accident and emergency department and in the trauma clinics makes the post of accident officer more interesting and attractive than if his duties were confined solely to the accident and emergency department, and provides a more integrated training. 10. A book of standing orders given to every member of the accident and emergency department and staff on appointment has proved invaluable in avoiding mistakes in both treatment and disposal of patients and has reduced the amount of repetitive instruction. 11. While we have clerical assistance until 10 p.m. each night, it would be better to have a clerical service throughout the 24 hours. 12. An accident and emergency department requires the help of a good geriatric service if there are to be enough beds available for the patients needing them and if a rapid turnover is to be ensured. 13. The admission of children to the accident ward which is largely populated by adult patients does not appear to have any deleterious effect on the children. After the acute phase, children are transferred to a children’s orthopaedic ward to complete their treatment and this is usually within 48 hours of admission. In the planning
Volume 3 Number 3
ACCIDENT SERVICES TODAY
of a new accident and emergency department a section set aside for the subsequent attendance of children for dresssings may be an advantage. It is, however, more important that children receive the facilities
of a full accident
specializing
in the treatment
that they are housed
team
in a unit
of trauma
in a children’s
than
ward, being a
solitary accident case amongst other conditions Requests
for
reprirm
should
be addressed
to:-A
THROMBO-EMBOLISM Postoperative Deep Venous Thrombosis Seventy-five patients over 45 and submitted to abdominal operations were used to study the comparative value of clinical examination, ultrasound, phlebography, and 126iodinated fibrinogen in the diagnosis of thrombosis. They were examined on each of 11 days, starting with the day before operation. lzSIodinated fibrinogen revealed more thrombi (33 per cent) than the other methods; 18 thrombi diagnosed in this way were also revealed by phlebography, 5 were not. Compared with scanning, clinical examination was only 50 per cent accurate and ultrasound 33 per cent accurate. In no case did scanning fail to demonstrate thrombi that were diagnosed by other means but only 2 of the 37 thrombi it revealed were shown to be above the knee. For diagnosing thrombi, iodinated fibrinogen is most reliable but for revealing the source of a pulmonary embolus phlebography ispreferable. MILNE. R. M.. GUNN. A. A.. GRIFFITHS.J. M. T.. and RU~KLEY, i:. V. (1971), ” Postoperaiive Deep Venous Thrombosis ‘, Lancet, 2,445. Stimulation of Fibrinolytic Activity Comparing two groups of 27 persons undergoing elective operations the authors found an enhancement of fibrinolytic activity in the group that received phenformin and ethyloestrenol for 6 weeks. They regarded this as justifying a clinical trial of these drugs in an attempt to reduce postoperative thromboembolism. BROWN, I. K., DOWNIE, R. J., HAGGART, B., LI~LER, J., MURRAY, G. H., ROBB, P. M., and SANTER, G. J. (1971), ‘ Pharmacological Stimulation
of Fibrinolytic
Activity
in the Surgical
where the specialized available. NAYLOR,
care for trauma
is not
REFERENCES A. (1967), ‘ The Bradford Accident Service
(1960-1965) ‘, J1.R. CON. Surg. Edinb., 12, 264. WILSON, D. H. (1963), ‘ Incidence, Aetiology, Diagnosis, and Prognosis of Closed Abdominal Injuries: a Study of 265 Consecutive Cases ‘, Br. J. Surg., 50,
381.
Naylor, Esq., Ch.M., MSc., F.R.C.S., 3 MorningtonVillas, ManninghamLane, Bradford8.
ABSTRACTS
Lancet,
157
Patient ‘,
1, 774.
Prevention of Postoperative Deep Venous Thrombosis Hydroxychloroquine reduces the tendency of platelets to stick together and form clumos from which potentially fatai thrombi can grow. ‘The drug was given to three groups of patients in 200 mg. doses, starting with prernedication for operation and thereafter every 8 hours until they left hospital. It was given by mouth or by injection. In one group no patient receiving hydroxychloroquine showed any
clinical evidence of thrombo-embolism, whereas 9 per cent of the control group showed such evidence. When thrombosis was diagnosed by phlebography between 5 and 12 days after operation, 23 per cent of the control group showed thrombosis whereas none was found in the patients receiving hydroxychloroquine. In their guarded comments the authors regarded these results as encouraging. CARTER, A. E., EBAN, R., and PERRETT, R. D. ‘ Prevention of Postoperative Deep Venous (1971), Thrombosis and Pulmonary Embolism ‘, Br. med. J., 1, 312. Heparin for Deep Vein Thrombosis The effect of small doses of heparin on the incidence of thrombosis of the deep veins of the lower limb was studied in a controlled trial on 53 persons undergoing repair of hernia over the age of 50. One of 26 (4 oer cent) of those that were eiven heoarin were shown 6y meat& of ‘?odinated f?brinogin to have developed thrombosis, in contrast to 7 of 27 (26 per cent) of those that were not given heparin. Five thousand units of calcium heparin were given by subcutaneous iniection 2 hours before and 24 hours after operation a”nd every 12 hours for the next 5 days. The success of this small dose is explained by the fact that before thrombi have begun to form the-naturally occurring inhibitor of Factor X is much more easily reinforced by heparin than when the delicate natural balance between thrombogenesis and thrombolysis has been tilted towards thrombosis. The limitations of the study are admitted, but as the authors point out, the method of trial can be widely applied. KAKKAR, V. V., FIELD, E. S., NICOLAIDES, A. N., FLUTE, P. T., WESSLER, S., and YIN, E. T. (1971),
‘ Low Doses of Heparin in Prevention Thrombosis ‘, Lancet, 2, 669.
of Deep Vein
Prevention of Pulmonary Embolism The efficacy of dextran 70 in preventing pulmonary embolism was studied in a controlled series of hiehrisk patients (fractures of pelvis, hip, and femoral shaft). There was a considerably lower incidence in the treated group. This group also showed a decrease in platelet adhesiveness and plasma fibrinogen. The higher incidence of bleeding from the surgical wound in some of the treated group is referred to as not significant. In the discussion, rkgimes based on anticoagulants are somewhat summarily dismissed. ATIK, M., HARKESS, J. W., and WICHMAN, H. (1970), ‘ Prevention of Fatal Pulmonary Embolism ‘, Surgery
Gynec. Obstet.,
130,403.
IYJURY:
THE
BRITISH
THE BRADFORD
JOURNAL.
Ot
ACCIDENT
ACCIDENT
SURGER1
SERVICE
A. NAYLOR Comrltant in Accident and Orthooaedic Surgery, Orthopaedic Hospital, Rawdon, ir. Leeds Bradford Royal Infirmary (540 beds) and Bradford St. Luke’s Hospital (720 beds) together with the Children’s Hospital (83 beds) are the major general hospitals serving an urban population of approximately 500,000. An orthopaedic department was opened in the two major hospitals in 1945 under one orthopaedic surgeon. There were 50 beds for mixed accident and orthopaedic cases in each unit and each had a casualty department, although the major casualty department was at the Bradford Royal Infirmary. A few beds were available for children in the Children’s Hospital where injured children were taken to a small receiving room. A second surgeon was appointed in 1946. In 1954 some concentration was possible by the improvement and conversion of a convalescent hospital on the outskirts of the city to become Woodlands Orthopaedic Hospital ( I I2 beds). The in-patient department of St. Luke’s was then closed and only outpatient clinics and a receiving room maintained there. All the major road accidents were then directed to the Royal Infirmary, but it soon became evident that it would be impossible to staff a casualty department adequately for 24 hours per day in three hospitals, each separated by one and a half miles. Thus, in June, 1960, the casualty departments at St. Luke’s Hospital and the Children’s Hospital were closed and the department at the Bradford Royal Infirmary was adapted to become the sole accident and emergency department for the hospital group serving the above population. This was effected after discussion with the local medical committee and subsequent newspaper advertisement and publicity. All trauma was then concentrated in the former orthopaedic wards of the Bradford Royal Infirmary (62 beds-31 for each sex) and non-traumatic orthopaedic conditions, including those of children, were dealt with at Woodlands Orthopaedic Hospital. The 62 beds are now utilized solely for trauma with the exception of burns, and injuries to the eye, ear, nose and throat. The last two groups have always been, and still are, treated exclusively in their respective departments and out-patient emergencies of these THE
Bradford Hospitals
ntld Woodlmcls
do not attend the accident and emergency departments. Burns, stab wounds, and gunshot wounds of chest and abdomen are admitted directly to the general surgical and thoracic surgical wards, but with these exceptions, all forms of trauma are admitted to the accident unit which, together with the accident and emergency department, is under the direct supervision of the consultant orthopaedic surgeons, the senior being the administrdtive head of the unit. Other specialists are called in on suspicion of such injury by the orthopaedic consultants, or in extreme emergency by registrars, to examine, advise on, and treat the injuries of their specialty, itr the unit. The accident and emergency department and the accident and orthopaedic service provided are staffed by three consultant orthopaedic surgeons. A fourth orthopaedic surgeon recently appointed will take LIP duties in the near future. The junior orthopaedic surgeon undertakes definitive sessions in the accident and emergency department in addition to his normal accident and orthopaedic duties. He holds a special clinic for all infected hands once a week and once a week he conducts an instruction and training session, which all accident officers must attend. For the smooth working of the department, each consultant orthopaedic surgeon will see each other’s patients as necessary, particularly in the early stages of treatment. No surgeon has any particular number of beds, the beds being available in the unit as required. The unit has the advantage that the accident and emergency department and the orthopaedic and fracture clinics are one selfcontained department of the hospital, thus ensuring that one unit is responsible for treating all types of injury, major and minor. We have changed the name of the fracture clinic to trauma clinic as both fractures and major soft-tissue injuries are seen here. It is so arranged that an orthopaedic consultant is in the department, either in the accident and emergency section or in the fracture or orthopaedic clinic every morning or afternoon of each weekday. Each orthopaedic surgeon is responsible for the same two admitting
Volume Number
3 3
ACCIDENT
SERVICES
days per week, for all attendances and admissions to the accident and emergency department and the accident wards. The additional medical staff are:1. A senior orthopaedic registrar who takes part in a rotation scheme of training with the two teaching units in the region. 2. Three accident and orthopaedic registrars, each working with one orthopaedic surgeon and responsible with him for the treatment of all accident and emergency attendances, accidents, and the non-traumatic patients in his charge and for those who attend on his admitting days. He also takes part in the treatment of the nontraumatic orthopaedic cases at the Woodlands Orthopaedic Hospital, the orthopaedic outpatients and fracture clinics, thus obtaining a complete training in all aspects of orthopaedic work. He is on call for the accident and emergency department while on duty for his chief’s admitting days. The junior registrar is one of four taking pan. in a two-year rotational Fellowship training programme, which consists of one year of general surgery, six months of thoracic surgery, and six months of accident and orthopaedic work. He usually works with the junior orthopaedic surgeon. 3. Junior sta$ Until a year ago there were five accident house officers (senior house officers) working in the accident and emergency department which is recognized for the F.R.C.S. Casualty requimments. This was increased to six earlier this year. In addition to work in the accident and emergency department, they partake in the work of the accident wards and attend at operations and fracture clinics, but they have no responsibility for the ‘cold’ orthopaedic clinics and patients. They attend a weekly teaching round, togethewith the ward rounds in the accident unit which are conducted by each of the consultants with their staff, in addition to visits whenever requred for an emergency and as necessary on their take-in days. There are normally 16 general practitioner clinical assistant sessions in the accident and emergency department. These cover every afternoon and some morning sessions. The aim is to provide three accident officers each morning, two in the afternoon and two each evening to I I p.m. From I I p.m. to 9 a.m. one accident officer is on duty. To allow the accident officers time for reading, instruction, anld attendance on their accident the afternoon sessions are covered wards, entirely by general practitioners. As an orthopaedic consultant is in the combined accident and emergency and orthopaedic department during
TODAY
149
this time, senior advice and help is readily available. The discrepancy between the number of junior hospital posts and the available doctors to fill them, partly due to the recent decline in the number of overseas graduates, has necessitated a change in the pattern of junior staffing. At present there are three accident officers who work part-time in the accident wards, the theatre, and the accident department, but the department is now staffed from 9 a.m. to 5 p.m. by increasing the general practitioner sessions, and some sessions in the evening are also covered by these doctors. Assistance after 5 p.m. until 9 a.m. next morning is now given by all grades of junior staff, including senior registrars who undertake these additional sessions with payment, and on a volunteer basis. 4. Nursing stafl The accident and emergency section has two experienced sisters in addition to the department sister, and there are four full-time and six part-time staff nurses, equivalent to seven staff nurses, and six nurses in training working in the department between 7.30 a.m. and 10 p.m. After IO p.m. there is one sister who can call additional auxiliary and pupil nurse help. Another sister with three part-time staff nurses and a ward orderly are responsible for the plaster room and orthopaedic and fracture clinics. Three full-time plaster orderlies are on duty from 9 a.m. to 6 p.m. to assist in the orthopaedic and fracture clinics and with the treatment of fresh accidents. Members of parachute regiments attend for instruction in the care of the injured. 5. Secretarial assistance. Adequate secretarial assistance is essential for the smooth running of an accident and orthopaedic unit. There are two full-time and two half-time departmental secretaries, one of the latter helping with clerical duties in the accident and emergency section. All notes of patients in the orthopaedic and trauma clinics and in the accident wards are typed and all documents and radiographs for current patients are filed in the department until the patient is discharged from the unit. Every patient attending the accident and emergency unit has a letter sent to his or her doctor. Initially these were typed, but in view of the varying number of the accident officers now working in the unit, a pro-forma letter written out by the accident officer at the time of the patient’s attendance has replaced the typed letter. We think it essential that every doctor should have a letter about his patient, the treatment which has been given, and what future treatment is contemplated. New and follow-up patients who attend the trauma and orthopaedic clinics are seen by
I 50
INJIJRY: I lit
hlJL,r\
BKITISH JOURNAL (II A(‘C1L)t.NI SI:RtiER\
appointment. In the accident and emergency section return visits are also by appointment, these being staged throughout the day from 9 a.m. until 6 p.m. and on Saturday mornings until I p.m. This reduces the risk of a large number of follow-up patients interfering with the reception and treatment of new patients, and is the only possible way of preventing the department from being over-run by large numbers of patients at any one time. The reception and records department is manned by clerical staff from 9 a.m. to 10 p.m. every day, including week-ends and holidays, but 24-hour cover is desirable as reception duty by nurses after the working hours of clerical staff, while possibly not arduous, is wasteful of valuable nursing staff. In the reception area there are voluntary receptionists who help to direct patients to the various sections of the unit, thus maintaining a smooth flow. One member of the hospital administrative staff is delegated to see that the administrative arrangements of the department run well. Direct telex links with the ambulance depots are maintained from the hospital. A room adjacent to theaccident department is set aside for the collection of all patients who have to be taken home by ambulance and in this room a member of the ambulance staff is in attendance to operate the telex system. Here arrangements are made for the subsequent collection of patients by ambulance for clinics of all types. There is no direct radio-telephone link between ambulance and emergency department, but there should be. Three operating sessions are held each week. Each consultant orthopaedic surgeon conducts an operating session together with his registrar and sometimes the senior registrar, for the nonurgent operations on trauma cases, two theatres being in full use during these sessions. In these sessions, operations for fractures of the neck of the femur, open reduction of fractures, together with nerve suture, tendon grafts, and bone grafts are undertaken. Minor cold orthopaedic operations for out-patients such as ganglia and nerve entrapment release are also undertaken on these lists. The more urgent cases needing operation are dealt with on the next available list, whichever surgeon is responsible for their care. Emergency cases can be dealt with readily in one of the main operating theatres, where the necessary staff is available. The stretcher reception room has six stretcher bays, each equipped for the resuscitation of any emergency, but unfortunately we have no space available for separate resuscitation facilities.
1972
.I,*n
The department has its own radiograph unit tiith apparatus capable of the radiography of all parts of the body and an automatic processing unit, a 24-hour radiographer service being provided. At busy times radiography for backache is undertaken in the main radiology department to relieve congestion in the accident unit. Dressing cubicles are available for both clean and ‘ dirty ’ dressings, it being important that these two divisions be separated, each having its own appointments system. The department has a ‘ clean ’ theatre where lacerations can be sutured and there is a * dirty. theatre for septic cases. To avoid cross-infection regular tests are made by the consulting pathologist responsible for the control of infection in the hospital. No ’ cold ’ minor operations are undertaken in the department, it being essential to reserve the theatres in the accident and emergency department solely for accident cases. Fractures are manipulated in the orthopaedic plaster room adjacent to the unit radiology department. TYPE
OF CASE SEEN IN THE ACCIDENT AND EMERGENCY SECTION
It is important from ambulance Tdh
/.-TYPE
ACCIDENT
to separate walking patients patients and, if possible, to OF NEW
CASE A-WENDING
THE
AND EMERGENCY DEPARTMENT
TYPF OF CASE
Non-emergencies (walked-in-referred back to doctor without treatment) Fractures Bone and joint injury (no fracture on radiograph) Lacerations, including muscle and tendon iniuries (hand iniuries included in the above three categories 13 per cent of these) Head injuries Chest injuries Sepsis in limbs, hands, and feet Perianal and breast infection Dog bites Burns and scalds Poisons and overdoses Medical Drunk Foreign bodies swallowed Abdominal emergencies on 999 calls Gynaecological (abortions, haemorrhage) Genito-urinary (retention) Dental E.N.T. (foreign bodies in nose) Miscellaneous (rings too tight, stings)
PERCENTAGE
2.2 14.3 37.3
22.0 3.0 0.15 3.7 0.15 1.9 4.4 3.0 2.0 0.15 0.9 0.3 0.3 0.15 0.9 0.15
1.o
Volume 3 Number 3
ACCIDENT
SERVICES
maintain two separate lines of patient flow. The aim is to confine attendances in the department strictly to accidents and emergencies. If other than these atter,d (which amount to 2.2 per cent of all cases) they are usually referred back to their doctor, or if the occasion seems fit, to the appropriate consultant’s clinic. If such a case is referred by a general practitioner to the accident
0 16
1
,,,,I 7 6 9 10 11 12 -8 -9 -10 -11 -12 -1
7 -8
F(g. 1.-Case
8 9 xl 11 12 -9 -a -11 -12 -1 A.M.
TODAY
151
included in those attending the major follow-up clinics which are held three times weekly at which a consultant is in attendance. Between 100 and 120 patients are seen at each of the major clinics. The remaining three trauma clinics are held by the orthopaedic registrar on call, the patients having appointments given to them on their first attendance at the accident and emergency
3 -4
L -5
5 -6
6 -7
7 -6
9 9 10 11 12 -9 -10 -11 -12 -1
1 -2
1 2 3 -2 -3 -I P M.
L -5
5 -6
6 -7
7 -6
8 9 10 11 12 -9 -10 -11 -12 -1
1 -2
1 -2
2 -3
load of attendances at accident and emergency department. (Reproduced by kind permission of the Editor of the ‘Journal of the Royal College of Surgeons of Edinburgh’.)
and emergency department, it is referred back to him with a polite note suggesting that he might care to send the patient to a consultant of his choice as the patient is not suffering from an emergency condition, and the accident and emergency department is not a consultative clinic. An urgent out-patient appointment can always be obtained by the practitioner by direct request to the appropriate consultant. Table I lists the different types of case attending the departmem, showing the preponderance of orthopaedic conditions. Attendances in the accident and emergency department progressively increased until 1967, since when they have remained steady at approximately 42,000 new attendances per year. Our aim is to minimize return visits to the department and to use this section as an initial treatment and sorting unit. Patients with fractures, joint injuries, or any patient who has had a plaster cast applied, must attend the trauma clinic next day, this being held every day except Sunday. These patients are
department. Subsequent attendances are distributed to the three major trauma clinics, patients being followed up by the consultant who was responsible for their care on their first attendance. A study of the times of appearance of new patients in the accident and emergency department is helpful in allotting medical and nursing staff to the department at different times of the day. Fig. 1 shows a steady rise in the number of patients attending between 8.30 a.m. and 10 a.m., followed by a steady fall until lunch time. A further small rise occurs between 1.30 p.m. and 3 p.m. when a rapid fall occurs with few attendances until a rise appears at 7 p.m. This is attributed to the accidents which have occurred towards the end of the working day and to those who have been referred by their family doctors. On Saturday a further small rise usually occurs between 10 p.m. and 11 p.m. Minimal staffing is One thus required between 4 p.m. and 6.30 p.m. medical officer is allocated to the reception of
152
INJURY:
THE
BRITISH
JOURNAL
walking patients while another undertakes duty in the stretcher reception room. Fractures are treated in the plaster room where a small recovery room is available. The patient is asked to read the printed pamphlet dealing with possible complications after fracture reduction and plaster application. This also tells him about necessary finger movements, with advice to return if any complications arise and what the signs of these are. An appointment for the next day’s trauma clinic is then given to him. Patients who can be appropriately treated by their general practitioner, works doctor, or works nurse for dressings or removal of sutures are referred back to them and no return appointment made. Table I shows that approximately 30 per cent of new attendances are for the treatment of lacerations, abrasions, and puncture-wounds. Fifty per cent of attendances are for joint and limb injuries or for the exclusion of bony injuries and of these about 14 per cent prove to have fractures. The importance of tendon, joint, and closed soft-tissue injury in the absence of a fracture is constantly stressed to the departmental staff. Eye and ear, nose, and throat emergencies go directly to the out-patient department of those units. After 5 p.m. and until 9 a.m. they attend the accident and emergency department but are seen exclusively by the ophthalmic and E.N.T. staff and do not enter into the normal patient flow of the department. Two per cent of admissions are classified as medical emergencies who have been brought to the hospital directly without visiting their own doctor, while 2.5 per cent of the cases are those of poisoning and attempted suicide, adding up to a total of 4.5 per cent of admissions which are a medical responsibility. One consultant physician manages all cases of poisoning and after their initial examination subsequent treatment and admission are undertaken by his staff, and the accident and emergency department has no further responsibility. There has been an increase in medical emergencies over the past five years, largely because a coronary care unit is stationed in the Bradford Royal Infirmary and this serves the whole hospital group. If the admission of a medical emergency is necessary, a member of staff of the medical division is sent for and he has the responsibility for arranging admission and whatever treatment is necessary. As there is no separate provision for the examination and treatment of medical emergencies in the restricted space of the accident and emergency department, a time limit of about 20 minutes has had to be made, after which failure of the member of the
OF
ACCIDENT
SURtiERL
Jan.
InJury 1972
medical division to attend the case will result in the patient being admitted to their ward. It should be emphasized that the accident officer on duty has complete authority to admit any case to any department he considers necessary in emergency. All accident officers are given an instruction book containing a series of standing orders in the department, referring particularly to the disposal of cases, to the times of consultant orthopaedic and fracture clinics, and dealing with procedures to be undertaken in specific circumstances, e.g., where admission for social, rather than medical purposes is necessary, or where reference to other departments and consultant clinics may be required. The booklet also gives brief notes on the treatment of common conditions as indicated by the individual consultants, and particularly on which patients /trust be admitted, e.g., all children with supracondylar fractures and any patient who gives any history of unconsciousness, however momentary, following a head injury. The book also contains a scheme of wound treatment, antibiotic therapy, No anti-tetanic and anti-tetanus treatment. serum is used in the department, it being the practice of the unit to give tetanus toxoid together with an antibiotic for prophylaxis, this being combined with adequate wound cleansing or excision as indicated. Cases of burns which can be treated as outpatients are seen at a weekly burns clinic held by the plastic surgery department, in the accident and emergency unit. The use of inflatable plastic splints for temporary splintageof limbs, while awaiting radiography or attention to their fractures, has proved invaluable. ADMISSIONS
TO THE
ACCIDENT
UNIT
Patients needing admission are moved to the accident ward under the care of the orthopaedic surgeon of the day, who assumes responsibility throughout for the whole patient and co-ordinates the activities of the other consultants taking part in his treatment. In the ward a further examination is made, the orthopaedic registrar on duty being called to every admission. When the orthopaedic injury is combined with injuries to other systems the appropriate specialist is summoned by the orthopaedic consultant or, in emergencies, by his registrar. A general surgeon is summoned for abdominal injuries, the thoracic surgeon for major chest injuries, and the urologist for injuries of the genito-urinary system.
Volume 3 Number 3
ACCIDENT
153
SERVICES TODAY
Head injuries are under the care of the orthopaedic surgeon scting under the supervision of a visiting neurosurgeon. The latter visits the unit once weekly and on request in a specific emergency. Any cases requiring expert neurosurgical attention are transferred to the unit at Chapel Allerton Neurosurgical Centre, Leeds, IO miles distant, but in an extreme emergency a burr-hole and initial neurosurgical treatment can be instituted in the accident unit by the orthopaedic staff, a sterile naurosurgical instrument set being kept in readiness at all times. Patients with burns are admitted to the care of the general surgeon of the day, but patients with burns of the hands and face are transferred to the plastic surgical department; major burns are transferred to the Regional Burns Unit at Pinderfields Hospital, 16 miles distant, but only after resuscitation has been begun. The majority of admissions to the accident ward are those of injuries to limbs (70 per cent). Many are assoc ated with head injuries of varying severity, but about one-third of admissions are for the observation of head injuries alone. A special system of recording the clinical and neurological stete of such a patient is instituted immediately he arrives in the accident and emergency department and continues throughout his stay in the accident ward, where half-hourly records of pupils, pulse, blood-pressure, temperature, and conscious state are maintained. An intensive care unit headed by a consultant anaesthetist provides four beds where severe multiple or hlzad injuries, particularly those needing ventilation, are admitted, but they are transferred to the accident unit as soon as feasible. While the responsibility for the patient rests with the orthopaedic surgeon, the anaesthetist decides on the timing of this transfer. The number of admissions to the unit showed a rise from 2050 in 1961 to 2600 in 1964-5 and the early part of 1966. The projection of this curve at that time showed that the number of cases likely to require admission would be in the region of 2700. This has been shown to be correct and the admissions in 1970 showed a slight increase on these estimates. To accommodate this increase, we have successfully reduced the bed occupancy from 9.37 days per patient to 7.72, but it is evident that the unit is becoming too small both to dl:al with the number of in-patients and out-patien1.s attending the department. On numerous occasions the accident unit is filled to overflowing and patients from the unit have to be ’ slept out ’ in other wards to accommodate the new admissions. The promised new unit of
100 beds with a neurosurgical department and associated staff, new out-patient department and wards has still not yet reached the planning stage. Twenty-eight per cent of admissions are female, of which many are suffering from fractures of the femoral neck, while 58 per cent of admissions are males. Of those patients admitted, 14 per cent have been children. They are detained in hospital for the immediate acute phase, those requiring further hospital stay being transferred to Woodlands Orthopaedic Hospital to continue their treatment there. The majority of children, however, are admitted for observation of relatively minor head injuries and they stay in hospital for two or three days only. ANALYSIS
OF CASES
ADMITTED
The ratio of severe to mild head injuries is approximately I : 6 in males and still fewer in females. Limb injuries, e.g., fractures of long bones, are often multiple, and make up 65-70 per cent of the admissions. Any discussion on accident units, and pariicularly their staffing, is usually highly coloured by reference to the treatment of multiple injuries. These, of course, are very dramatic and serious and do require highly trained experienced staff available at all times of the day and night. Any accurate assessment of the problem is difficult when one tries to define what is included in the ’ multiple injury ‘. The Platt Report category stated that an average of 2 per cent of admissions consist of multiple injuries. Our own figures, based on a definition of a head (and/or chest) and two or more major limb injuries, show that approximately 5 per cent of admissions have severe multiple injuries, but these figures are likely to vary with the proximity of the hospital to a motorway, where injuries to more than one system are likely to be more frequent. I feel, however, it should be emphasized that in an average large industrial town such as Bradford (and the majority of hospitals are not near motorways), one must budget for the treatment of the far more numerous and less sensational limb injuries, but must, in addition, be able to deal with the more complex multiple injuries at the same time. The organization should undertake the treatment of all types of injury, major or minor, and thus the accident and emergency department should not have a separate staff or head of department. The entire accident service should be one functional, geographical, and organizational entity, staffed throughout by the same surgeons. No single specialist (e.g., an ‘ accident surgeon ‘) can be sufficiently experienced and expert in all
154
INJURY
: I’HE
BRITISH
JOURNAL
special branches of surgery with their increasing complexity to deal with all, and therefore teams of consultants in all specialties have to be available to deal with the different aspects of multiple injuries, the orthopaedic surgeon acting as co-ordinator while dealing with his particular aspect. Thus the expert should be available initially, where his special experience is so essential and not engage in treatment at ’ second hand ‘. Abdominal
Injuries
The rarity of abdominal injuries in civilian practice is noteworthy. In our unit they form no more than 0.2-0.4 per cent of the total injuries, i.e., only 4-6 patients per year, out of a total of 2500-2700 admissions, require laparotomy. Genito-urinary injuries have a similar incidence. This approximates to the figures published in a ten-year series in Leeds (Wilson, 1963) where only I in 914 accident admissions (0.1 per cent) had an abdominal injury. This infrequency reinforces the argument that such injuries should be dealt with by the duty general surgeon who is dealing daily with abdominal conditions, rather than by an accident surgeon who might have to open the abdomen on the few occasions demonstrated by these figures. Thoracic
Injuries
Chest injuries requiring a thoracic surgical procedure form 0.5-0.8 per cent of admissions to the unit, but the frequent association of thoracic and upper abdominal injury is constantly stressed to the junior staff in the accident and emergency department. Our thoracic surgical colleagues are frequently consulted on the management of respiratory problems of patients admitted to the accident unit, even though the chest injury may be apparently minor. In recent years, direct injuries to the thorax, involving stab and gunshot wounds, have unfortunately been increasing and between 1961 and 1965, I6 stab and 3 gunshot wounds of chest were admitted directly to the thoracic surgical department. Plastic Surgery Maxillofacial injuries and problems of skin loss and replacement are treated by our plastic and oral surgeons. Head Injuries Approximately 40 patients per year are transferred to the neurosurgical centre in Chapel Allerton, Leeds. Head injuries carry a high mortality ranging from 15 per cent in the O-15
(II-
ACClDtN
I
SIJRGtRY
age-group and 24 group, while it rose the age of 60, and cent of the patients Fractures
IilJUr} .Irlll.
1972
per cent in the 15-60 ageto 60 per cent in patients over these latter comprise IO per transferred.
of the Neck of the Femur
Many patients with fractures of the neck of the femur are admitted, most of them being female. In 1961 there were 271 such admissions, amounting to 5 per cent of the total admissions to the unit and threequarters of them were female. This number has reduced recently over the past 7 years because of the opening of additional units in the area formerly drained by this hospital, but we still admit 190-200 fractures of the neck of the femur each year. The majority are treated by some operative method, which requires considerable theatre time and staff. An active geriatric service working in close association with the orthopaedic department has allowed the early removal of patients with social problems, and it is only by this means that so many patients can be accommodated in a unit of this size which deals with such a large total. Major Catastrophes
outside the Hospital
A plan has been evolved to deal with a major accident or catastrophe within the area served by the hospital, from which a team consisting of a surgeon, an anaesthetist, and two sisters, with special equipment in the accident and emergency department, is despatched to provide essential surgical treatment and resuscitation at the site of the incident. A rehearsal of this scheme is conducted at intervals in co-operation with police, fire, and ambulance services. Rehabilitation
Facilities
The accident unit is visited daily by one of the physiotherapy staff for group exercise therapy, with subsequent individual treatment. A large physiotherapy department supervised by an orthopaedic consultant is situated below the accident wards, near the accident and emergency and a school of physiotherapy department, attached to the hospital group and centred at the Bradford Royal Infirmary is provided with the opportunity to gain a large experience in the treatment of all forms of trauma, including the patients in the intensive care unit. Non-diversional occupational therapy is unfortunately available only at another hospital in the group. In-patient diversional therapy is available in the accident wards. The solitary social worker attached to the accident and orthopaedic unit is invaluable, but such a number is woefully
Volume 3 Number 3
ACCIDENT SERVICES TODAY
inadequate. Application to set up an industrial rehabilitation unit attached to the hospital has been made on .two occasions with scant success. It was intended that this unit should supplement the available facilities provided by the Department of Employment and Productivity, and would aim at providing a protected workshop with a view lo returning the patient to his normal pre-accident work, i.e., it would act as a ‘ toughening-up ’ centre, before return to full work. The initial approach was ignored completely by the Regional Board, Management Committee, and members of industry in the town. A subsequent approach, however, gained benevolent approval if the money could be raised outside the service, and approaches were made to local industry and to trade union representatives. The appalling lack of interest, however, was quickly evident, all relevant parties pointing out that there is little or no financial incentive for a patient to work. in a protected workshop until he became fit to take his normal place in his preaccident work. It is hoped that this type of rehabilitation facility will be provided in the new accident unit when it is built. CONCLUSIONS FROM OUR EXPERIENCE OF THE PAST TEN YEARS 1. The benefits of concentrating accident and emergencies in few centres has been evident. In the west of the Leeds Region, including the City of Leeds itself, there are now 8 centres dealing with a population of over 3 million. These centres each provide a 24-hour service and they demonstrate amply that much greater concentration along these lines could be undertaken in other areas in this country with advantage, with improvement in the services provided, and with some saving of manpower. 2. It is essential that an accident and emergency department should not act as a second general practitioner surgery. Publicity campaigns to the general practitioners via the local medical committee and to the general public via the press and mass media, have helped our department to put this into active practice and to maintain the department solely as an accident and emergency department. A.rrangements should be available for general practitioners to have their patients with urgent conditions seen at the next available clinic by direct application to the consultant. It is important that the accident and emergency department is not available as a second consultative clinic. 3. It is essential that the accident and emergency department and the orthopaedic out-
1.55
patient department should be physically and achitecturally one unit. This allows the constant presence of consultants and all grades of staff, who are then available at all times in the department, and can thus exercise a close supervisory and consultative role in addition to the active management of acute accident cases. This allows the accident officers to be constantly supervised and taught by their consultants. Further, it allows a fully integrated accident and orthopaedic service which, with the aid of their colleagues in other specialties, can deal with accidents of all severities from the mildest to the most severe cases of multiple injury. 4. The concentration of all injuries in accident wards from which all other types of patients are excluded is essential to a comprehensive accident service. These patients should be the responsibility of the same person who sees them and is responsible for them in the out-patient and accident and emergency departments, i.e., the same consultant who was on duty on the day they were admitted and who was responsible for all accidents and emergencies attending the accident and emergency department on that day. The unit must be within a general hospital, thus ensuring the availability of all specialties. Accident teams with a co-ordinator readily available are essential and preferable to the ‘jack of all trades ’ accident surgeon. Such a structure obviates the need for observation beds in the accident and emergency department itself. It is often maintained that observation beds in such a department are unsatisfactory because they are difficult to staff and to keep patients under constant observation. We agree with this. Any patient requiring such observation should be admitted to the accident ward where all facilities are available for investigation and treatment of any accident case. The suggested national average of 35 beds per 100,000 is too small. In general, these beds have been included in those of specialties, mixed with non-urgent cases. It is essential that separate allocation for accident cases should be made. 5. Our experience shows that it is important to maintain a constant check on the return visits to the accident and emergency department and on the type of patient attending for the first time, so that any adjustment to the organization necessitated by changed circumstances can readily be made. Thus, the surgeon in charge of the accident and emergency department and the accident services in the hospital group should have time set aside for this aspect of organization in the relevant departments. It is still evident that
156
INJURY:
THE
BRITISH
JOURNAL
in the large majority of hospitals, despite good organization, facilities are quite inadequate for the number and types of conditions requiring treatment. Regrettably, our own department has virtually no waiting space for patients. Our patients still have to sit around in corridors, obstructing the regular flow of others. 6. The accident and emergency and orthopaedic department should have its own separate radiograph department strategically sited to facilitate patient flow and minimize movement of patients being resuscitated. While we have such a department excellently sited, it has proved to be too small and we now have to plan for its expansion, even in the present limited space. The importance of a separate radiograph department set aside for the accident and emergency service is still not appreciated, as is evident in the development and planning of new hospitals without this facility despite the fact that the necessity for it has been well publicized. 7. A large number of stretcher cubicles for the reception of injuries and emergencies brought in by ambulance is essential. Most departments have totally inadequate facilities for this. Our present department requires at least double the amount of space for such patients. Resuscitation rooms separate from general reception cubicles are essential. 8. It is important that all specialties should be responsible for the primary treatment of their own out-patient emergencies and it is regrettable that this is not yet appreciated or accepted in many areas. Individual consultants must be responsible for the primary care of the emergencies in their own specialty and such responsibility cannot be delegated to one general factotum in the accident and emergency department. The Royal College of Physicians has now recognized the necessity for such responsibility for medical cases and has recommended that all accident and emergency departments should have a physician responsible for the organization and treatment of medical cases attending the department, a step we advocated a long time ago (Naylor, 1967). Such a subsection of the accident and emergency department would need to be staffed by one or more consultant physicians, possibly the consultant physician of the day and his team of registrar and house officers. From the number of patients attending, this physician would not need to be physically present in the department all the time when on duty, but could be undertaking some duties in the vicinity of the department and be readily available for consultation and for treating the patient.
OF
ACCIDENT
SURGERY
Jan.
Injury 1972
A simple appointments system prevents overcrowding of the department by return visits at any particular time, thus allowing freedom of manceuvre of the staff to attend to any new cases. 9. The difficulty of staffing an accident and emergency department with junior staff below registrar grade is becoming more acute, and is likely to prove a permanent feature until larger numbers of new medical graduates are available. The deployment of general practitioners in our accident and emergency department has proved of considerable advantage both to the department and to the practitioners themselves. It is our experience that this is a department in which general practitioners can employ their skill and experience to great advantage to the hospital service, and allow them to partake in interesting work amongst their specialist colleagues. It is essential that they be given contracts with security of tenure so that they can plan their regular attendance at the department. Training of more senior staff to work in the accident departments to support the accident teams, i.e., to deal with emergencies and sorting as opposed to accidents only, could well be the same as a vocational training for general practitioners. The combination of work in the accident wards and theatre with that in the accident and emergency department and in the trauma clinics makes the post of accident officer more interesting and attractive than if his duties were confined solely to the accident and emergency department, and provides a more integrated training. 10. A book of standing orders given to every member of the accident and emergency department and staff on appointment has proved invaluable in avoiding mistakes in both treatment and disposal of patients and has reduced the amount of repetitive instruction. 11. While we have clerical assistance until 10 p.m. each night, it would be better to have a clerical service throughout the 24 hours. 12. An accident and emergency department requires the help of a good geriatric service if there are to be enough beds available for the patients needing them and if a rapid turnover is to be ensured. 13. The admission of children to the accident ward which is largely populated by adult patients does not appear to have any deleterious effect on the children. After the acute phase, children are transferred to a children’s orthopaedic ward to complete their treatment and this is usually within 48 hours of admission. In the planning
Volume 3 Number 3
ACCIDENT SERVICES TODAY
of a new accident and emergency department a section set aside for the subsequent attendance of children for dresssings may be an advantage. It is, however, more important that children receive the facilities
of a full accident
specializing
in the treatment
that they are housed
team
in a unit
of trauma
in a children’s
than
ward, being a
solitary accident case amongst other conditions Requests
for
reprirm
should
be addressed
to:-A
THROMBO-EMBOLISM Postoperative Deep Venous Thrombosis Seventy-five patients over 45 and submitted to abdominal operations were used to study the comparative value of clinical examination, ultrasound, phlebography, and 126iodinated fibrinogen in the diagnosis of thrombosis. They were examined on each of 11 days, starting with the day before operation. lzSIodinated fibrinogen revealed more thrombi (33 per cent) than the other methods; 18 thrombi diagnosed in this way were also revealed by phlebography, 5 were not. Compared with scanning, clinical examination was only 50 per cent accurate and ultrasound 33 per cent accurate. In no case did scanning fail to demonstrate thrombi that were diagnosed by other means but only 2 of the 37 thrombi it revealed were shown to be above the knee. For diagnosing thrombi, iodinated fibrinogen is most reliable but for revealing the source of a pulmonary embolus phlebography ispreferable. MILNE. R. M.. GUNN. A. A.. GRIFFITHS.J. M. T.. and RU~KLEY, i:. V. (1971), ” Postoperaiive Deep Venous Thrombosis ‘, Lancet, 2,445. Stimulation of Fibrinolytic Activity Comparing two groups of 27 persons undergoing elective operations the authors found an enhancement of fibrinolytic activity in the group that received phenformin and ethyloestrenol for 6 weeks. They regarded this as justifying a clinical trial of these drugs in an attempt to reduce postoperative thromboembolism. BROWN, I. K., DOWNIE, R. J., HAGGART, B., LI~LER, J., MURRAY, G. H., ROBB, P. M., and SANTER, G. J. (1971), ‘ Pharmacological Stimulation
of Fibrinolytic
Activity
in the Surgical
where the specialized available. NAYLOR,
care for trauma
is not
REFERENCES A. (1967), ‘ The Bradford Accident Service
(1960-1965) ‘, J1.R. CON. Surg. Edinb., 12, 264. WILSON, D. H. (1963), ‘ Incidence, Aetiology, Diagnosis, and Prognosis of Closed Abdominal Injuries: a Study of 265 Consecutive Cases ‘, Br. J. Surg., 50,
381.
Naylor, Esq., Ch.M., MSc., F.R.C.S., 3 MorningtonVillas, ManninghamLane, Bradford8.
ABSTRACTS
Lancet,
157
Patient ‘,
1, 774.
Prevention of Postoperative Deep Venous Thrombosis Hydroxychloroquine reduces the tendency of platelets to stick together and form clumos from which potentially fatai thrombi can grow. ‘The drug was given to three groups of patients in 200 mg. doses, starting with prernedication for operation and thereafter every 8 hours until they left hospital. It was given by mouth or by injection. In one group no patient receiving hydroxychloroquine showed any
clinical evidence of thrombo-embolism, whereas 9 per cent of the control group showed such evidence. When thrombosis was diagnosed by phlebography between 5 and 12 days after operation, 23 per cent of the control group showed thrombosis whereas none was found in the patients receiving hydroxychloroquine. In their guarded comments the authors regarded these results as encouraging. CARTER, A. E., EBAN, R., and PERRETT, R. D. ‘ Prevention of Postoperative Deep Venous (1971), Thrombosis and Pulmonary Embolism ‘, Br. med. J., 1, 312. Heparin for Deep Vein Thrombosis The effect of small doses of heparin on the incidence of thrombosis of the deep veins of the lower limb was studied in a controlled trial on 53 persons undergoing repair of hernia over the age of 50. One of 26 (4 oer cent) of those that were eiven heoarin were shown 6y meat& of ‘?odinated f?brinogin to have developed thrombosis, in contrast to 7 of 27 (26 per cent) of those that were not given heparin. Five thousand units of calcium heparin were given by subcutaneous iniection 2 hours before and 24 hours after operation a”nd every 12 hours for the next 5 days. The success of this small dose is explained by the fact that before thrombi have begun to form the-naturally occurring inhibitor of Factor X is much more easily reinforced by heparin than when the delicate natural balance between thrombogenesis and thrombolysis has been tilted towards thrombosis. The limitations of the study are admitted, but as the authors point out, the method of trial can be widely applied. KAKKAR, V. V., FIELD, E. S., NICOLAIDES, A. N., FLUTE, P. T., WESSLER, S., and YIN, E. T. (1971),
‘ Low Doses of Heparin in Prevention Thrombosis ‘, Lancet, 2, 669.
of Deep Vein
Prevention of Pulmonary Embolism The efficacy of dextran 70 in preventing pulmonary embolism was studied in a controlled series of hiehrisk patients (fractures of pelvis, hip, and femoral shaft). There was a considerably lower incidence in the treated group. This group also showed a decrease in platelet adhesiveness and plasma fibrinogen. The higher incidence of bleeding from the surgical wound in some of the treated group is referred to as not significant. In the discussion, rkgimes based on anticoagulants are somewhat summarily dismissed. ATIK, M., HARKESS, J. W., and WICHMAN, H. (1970), ‘ Prevention of Fatal Pulmonary Embolism ‘, Surgery
Gynec. Obstet.,
130,403.