The war of the roads

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The war of the roads* R.S. Garden Consultant Orthopaedic Surgeon, Preston Royal Infirmary: Lecturer in Clinical Orthopaedic Surgery, University of Liverpool

I FIRST heard the name of Ruscoe Clarke during those eventful days when, like him, I was privileged to serve as a field surgeon in the 1939-45 war. Even then, his voice was raised above the din of battle, and his special interest in the care of the injured was already declared. His principal message-that the most important single factor leading to early death after injury is the loss of whole blood by bleedingwill appear to the young surgeons of today as a tiresome repetition of what they already know. But to the young surgeons at the beginning of the war this was not so. These men had come from civilian practice where blood for transfusion had not always been readily at hand. Many had been accustomed to bleed the donors and to do the cross-matching tests by themselves when the pathology departments had closed for the night. I can well remember thinking on those lonely occasions that the time was long overdue when blood for transfusion should be as easy to order as aspirin. Furthermore, it was the custom in the pre-war years to give transfusions of whole blood in pathetically small amounts, and it was a bold house surgeon or registrar who dared to exceed the niggardly limits of two or three pints that were then imposed. Not until the fighting in the Western Desert had lasted for some time did reports begin to filter through that some patients had survived the ordeal of blood transfusions amounting to as much as ten pints! This alarming intelligence was quickly followed by the information that recovery had occurred even after transfusions of thirty pints. This breakthrough-for such it was -changed the whole attitude to blood transfusion, and from then onwards the need to replace severe blood-loss with whole blood became slowly but increasingly recognized. It was

*Ruscoe Clarke Memorial Lecture delivered at the University of Birmingham, 25 April, 1972.

also recognized that blood transfusion is one of the most powerful weapons in the armoury of the accident surgeon, and that, like all powerful weapons, it must be handled with the greatest care. When Ruscoe Clarke returned to the haven of peace-time surgery with, as Lewin (1968) said, ‘ the dust of war upon him ‘, he pitched his tent in the Birmingham Accident Hospital. Immediately and perhaps to his surprise, he found himself engaged in yet another conflict-the war of the roads. So, he set his sights accordingly and flung himself into the task of still further improving the care of the injured. Just how well he Seddon succeeded is common knowledge. (1964) stated that Ruscoe Clarke made his name in the Accident Hospital at Birmingham, but the converse is also true. In large measure, Ruscoe Clarke made the name of the Birmingham Accident Hospital. History-even recent history-shows that the hard-earned lessons of one war have usually to be relearned at the beginning of the next, and advances in military surgery do not spill-over into civilian practice of their own accord. It was not by chance, therefore, that the painful lessons of World War II brought no greater benefit to peace-time surgery than in the field of blood transfusion; and no surgeon made greater efforts than Ruscoe Clarke to ensure that this lesson, at least, should not be forgotten. What does seem to be forgotten is the magnitude of this war of the roads, and it is curious that its daily toll of life and limb has failed to awaken the public conscience to the same extent as other and often lesser evils, which our demonstrators now denounce so loudly in the streets. This apathy is understandable, because road traffic accidents occur at widely scattered places and individual tragedies are reported mainly in the local press. Although the overall impact of the casualty figures is buffered in this way, the ugly fact remains that some 7500 people are

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killed and about 350,000 are injured on British roads alone every year. If those thousands of people were killed or injured in one day instead of in one year, and at one place instead of many, the public outcry would be enormous.

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lapses of concentration or errors of judgement, and not only children, but adults as well, are liable to do unpredictable things. So, human frailty being what it is, the spate of traffic accidents will continue, and it is sad to reflect that,

Fig. 1.

ROAD

ACCIDENTS

The word ‘ accident ’ implies an unforeseen happening for which no one can reasonably be held to blame. In this sense, road traffic accidents are rare. A number occur when some unexpected mechanical failure suddenly diverts a vehicle from its path, but most misadventures on the highway stem from vehicle neglect or human error. The driver who crosses a humpbacked bridge on the wrong side of the road, and who collides with another vehicle travelling on its lawful course in the opposite direction, does not deserve to mollify his guilt by hearing the incident described in the coroner’s court as an accident. A less dignified word is needed to define this kind of behaviour. Regrettably, however, each and every one of us is prone to

unlike conventional wars, the war of the roads will never end. How then can we play our part in this unceasing campaign? For one thing, we must neither underestimate the strength of the enemy nor ignore his powerful ally-greed. As a moment’s thought will show, cupidity is at the root of most of our troubles at the present time. The vehicle owner who seeks to squeeze the last shred of service from his brake-linings or tyres, and the manufacturer who cuts his costs at the expense of safety have much to answer for. The twin umbrellas of an insurance policy and a magnanimous Health Service invite a degree of recklessness which, in the absence of these protective shields, would certainly not be there. Every sensible motorist would then drive

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with great caution in the knowledge that, should a mishap occur, he or his executors would be responsible for the heavy costs of hospital treatment now being borne by the docile British taxpayer; for the repair or replacement of damaged vehicles and the massive compensation claims that are now met by the insurance companies; or for the crippling f19,OOO which the Road Research Laboratory workers have shown

reverse to the nearest passing place, and cheerfully wave his hand in greeting to the oncoming motorist, whose safe passage he has so willingly assured (Fig. 1). But, as likely as not, the same lorry on a two-way stretch of roadway will thunder down like some great harbinger of doom on the defenceless minicar heading in the opposite direction-all thoughts of tyre or mechanical failure apparently thrown to the winds (Fig. 2).

Fig. 2.

to be the price of every fatal traffic accident (Dawson, 1971). Again, we cannot overlook the disappointing finding that road improvements, in themselves, are not the easy answer to the problem. There is a picturesque Scottish highway winding Westwards to the Summer Isles which is wide enough for one vehicle only, and where motorists are given the choice of using the passing places provided or of plummeting down the face of a cliff to the cruel bed of the valley hundreds of feet below. On this road, the majestic scenery is matched only by the magnificent concern which each driver displays for the other. Road manners here are immaculate. The lorry-driver rounding a bend on this treacherous highway, and seeing another vehicle approaching, will often stop,

It seems to me, therefore, that the quality of road courtesy is in inverse proportion to the quality of the road itself: Whether this is true when three

lanes are provided for two-way trafhc is difficult to say. The lunacy of a middle lane, in which it is perfectly legal for two vehicles to travel at seventy miles an hour in opposite directions and at the same time, defies understanding. PREVENTION Prevention is the obvious watchword in the war of the roads, but preventive measures are not always wisely applied. Distracting posters bearing fatuous slogans at complicated road junctions-the very places where distraction should be most avoided-are more likely to cause than to prevent accidents (Fig. 3).

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Happily, the perilous advice to young children that they may safely cross the street after they have performed the ritual of looking right, left, and right again has at long last been supplanted

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and it is unfortunate that so few road-users have been persuaded to wear a seat-belt at all times. Many experiments have been made to study the effects of high velocity impact on dummies

Fig.

by the more sensible, though still imperfect, Green Code. Much progress however has been made in the fields of engineering, enforcement, and education (Palfrey, 1970), and, apart from our duty as ordinary citizens to further this progress, we, as accident surgeons, are in a specially favoured position to offer suggestions and advice. Sir Hugh Cairns (1941), the pioneer of crash helmets for motor cyclists, set us a fine example, and we should all be casting about for similar expedients to reduce the carnage of the roads. The logical conclusion to be drawn from the success of the safety helmet is that other appliances should be designed to protect the face, chest, abdomen, and limbs. In other words, reductio ad absurdum, the motorist should be encased in a suit of armour (Fig. 4). But many true words are spoken in jest, and the time may come when this suggestion will be less ridiculous than it now appears. For the time being, the seat-belt offers a measure of full-body protection,

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fitted with a restrictive harness, but the results of these experiments would be much more telling if they could be recorded, as it were, in the field. The accident surgeon is here presented with a unique opportunity to support the claim that injuries can be avoided or reduced by seatbelt protection. If every hospital reported the number of those who were wearing a seat-belt at the time of a road accident and the number who were not, this information could be regularly published as part of the national figures of road traffic casualties. If this were done for an experimental period of a year or two, the motoring public would be better able to judge whether or not they should strap themselves down in the box of their vehicle in the same way as they strap down and protect a fragile object sent in a box through the post. Once an accident has happened, preventive measures would seem to be no longer meaningful so far as that accident is concerned. Nothing

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can be done to avoid a catastrophe which has already occurred. When people are injured, however, much can be done to foresee and avoid the complications of injury, and prevention is then no less important a watchword after, than it is before, an accident. Just as injury can often be avoided by simple precautions, so also may its

Instead, we should bear in mind that our severely injured patients may not survive long enough to reach the intensive care units if their clinical care is not equally intense from the moment of injury until they can be handed over to the powerful and life-saving resources of these specialized departments.

Fig. 4.

complications be sometimes prevented by simple means. But simplicity of action in the face of serious injury is difficult to equate with the far from simple array of electronic monitors, intermittent positive-pressure ventilators, bloodand blood-gas analysers volume computers, which now lie in wait for the seriously injured. Although these expensive and intricate appliances are essential in the intensive care of the injured, they should also be seen to represent the dark jungle through which we are now threading our way to a better understanding of the problems of trauma and to the solution of these problems that will surely come in the fullness of time. This state of affairs is not peculiar to accident surgery. The answer to every problem is preceded by a long and frustrating journey through a forest of perplexities until at last the clearing in the woodland is found. So, we who are mere clinicians should not permit ourselves to be overawed by this elaborate instrumentation.

It is during this interval that much can be done to prevent complications or death, and it is an unenlightened accident surgeon who considers that his responsibilities begin only when the patient crosses the threshold of his reception room. What happens between the time of injury and the patient’s arrival in hospital should be of the utmost concern to those who man the barricades of the hospital emergency service. It is certainly of the utmost concern to the patient. Indeed, the quality of a patient’s care between the accident site and the hospital-the ‘ no-man’s land ’ in the war of the roads (Fig. 5)-is often of greater significance than the quality of his treatment when he is admitted to hospital.

EARLY

CARE

OF THE

INJURED

The introduction of Field Surgical Units was an important advance in the treatment of the wounded in World War II. The surgeon no longer waited for the injured soldier to be brought

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to him in the rear of the battle zone. Instead, he went forward to meet the soldier-or at least as far forward as his Field Commanders thought fit. And sometimes they thought a little too fit! In the final stages of the last war, the facilities afforded by the Royal Army Medical Corps for the treatment of battle casualties in the forward

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with rough wooden boards lashed to the limb by strips of parachute silk, and many hundreds crossed the Adriatic at intervals of as much as two years after wounding, in a distressing state of emaciation and toxaemia. If any proof were needed to highlight the value of resuscitation and early surgery, the pathetic

Fig. 5.

areas were of the highest order. The stillprecious supplies of penicillin were made available in generous amounts, portable X-ray equipment was provided, blood transfusion teams were always in attendance, and up-to-date anaesthetic apparatus and materials were freely given to the highly skilled anaesthetists, whose contribution to military surgery was so often taken for granted at that time. It was also taken for granted that a high proportion of those who were fortunate enough to reach a forward surgical unit alive could expect to survive and to escape infection of their wounds. The War Office figures for the last battle in Italy showed that from 90 to 100 per cent healing occurred in 85 per cent of 1853 wounds. In striking contrast, the Yugoslav Partisans, who were denied the advantages of resuscitation and early surgery, presented with atrocious deep-seated infections when they arrived in the British Military Hospitals in Italy that were deputed to undertake their care. Many of these remarkable people were transported across the mountains of their homeland on horseback, and fractures of the femoral shaft were prone to unite in a bizarre degree of outward angulation conforming to the curved splintage of the horse’s flank. Others were treated

state of these unfortunate freedom-fighters was evidence enough. No one who witnessed their plight could ever again wish to see battle casualties deprived of their right to blood transfusion, modern anaesthesia, and primary surgery.

IMMEDIATE

CARE

OF THE

INJURED

In relating these experiences to the war of the roads, I believe there is an important distinction to be made between the immediate as opposed to the early care of the injured. We should reach out to road accident victims and try to begin their treatment at the earliest possible stage. The doctor who feels that he has nothing to offer at the site of a road accident, because he carries no oxygen cylinders or splints, should remember that there is usually a fair proportion of oxygen in the surrounding air, and that splints are of secondary importance compared with the need to maintain the airway or to arrest accessible bleeding. Even without instruments or drugs of any kind, there is much that a medical man can do by using only his special senses, his voice, and his hands. He can see the degree of pallor, the patient’s demeanour, the state of his clothing, and the signs of external bleeding-all of which convey a wealth of information at a single glance. He can hear the gurgle of an obstructed

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airway, the characteristic sound of a sucking pneumothorax, or the intermittent hiss of arterial haemorrhage, and he is thus alerted to the need for urgent corrective measures. When a patient is unconscious, the distinctive smells of alcohol or acetone offer alternative diagnoses to that of head injury. (It is here an interesting aside to note that the traditional teaching, which likened the smell of acetoneladen urine or breath to the scent of new-mown hay, has now been exchanged for the new teaching comparing this smell to that of rotten apples. This, I think, is an apt reflection on the fact that so many of our children are now reared in towns and cities, and so few are allowed to grow up in the exciting and character-building atmosphere of the countryside. No child can be given a greater gift than this.) When a patient is conscious, the behaviour of the doctor himself is then of no less significance than that of the patient. The doctor who examines a recently injured victim of a road accident at the roadside or in the hospital, and who then walks away without a word, does great disservice to his patient and to his calling. By failing to exercise his prerogative as a member of our profession to offer comfort and reassurance to the injured, he lowers his status in the eyes of his bystanding nursing or ambulance colleagues. The anxious and wide-eyed victim of a road accident, who has no way of knowing how badly he is injured nor, indeed, whether he is going to live or die, will often respond in the most dramatic way to an off-hand or light-hearted remark which tells him that all will be well. The human mind, although it can normally deal with all manner of situations, is least able to cope with mystery. Any verbal comment, facial expression, or friendly tap on the shoulder, which dispels this mystery, can thus be regarded as the cheapest and most readily available form of resuscitation that we possess. I make no excuse for labouring the need for compassion in the care of the injured, because I feel that ordinary kindness is sometimes in danger of being swept away in the whirlpool of modern resuscitation procedures. But compassion alone is not enough. In the words of the anonymous poet : Friendship’s blind service in the hour of need, Wipes the pale face and lets the victim bleed. Science must stop to reason and explain, Art claps his tinger on the streaming vein. Ruscoe

maintain

Clarke’s

requirement

the blood-volume

that art must at its normal or near-

normal level, can just as well be met at the roadside by preventing blood from pouring from a patient’s wounds, as by the more dangerous practice of pouring someone else’s blood into his veins at a later stage. A surprising amount of blood can trickle away from even the smallest wound. This is particularly true of scalp wounds, from which several litres of blood can pump in a matter of minutes. To prevent this blood-loss at the accident site is akin to the setting-up of an instantaneous transfusion of the patient’s own blood. Local pressure can control bleeding anywhere in the body, and the arrest of haemorrhage from a laceration of the scalp is often simplicity itself. A well-directed finger, or the application of a spring paper-clip (Gibson, 1972), can make all the difference between life and death when uncontrolled bleeding from a scalp wound would otherwise tip the scales against survival, when internal haemorrhage has reached a critical stage. When there is no underlying fracture of the skull, a firmly applied handkerchief can be used as an emergency pressure pad. A recently laundered handkerchief is either sterile or surprisingly free from pathogens harmful to man. THE EMERGENCY SERVICES Unfortunately, the presence of a doctor at the scene of every road accident is an impractical ideal, but the hospital emergency service is supported by a whole army of paramedical workers, and its front-line troops-the ambulance attendants-are usually quick to reach the patient’s side. It is to them that we must look for those simple preventive measures in the field that can often decide the patient’s fate. It is patronizing to regard the ambulance attendants as mere stretcher-bearers. They are the vanguard of the hospital team, and, as such, they bear much responsibility for the immediate care of the injured. The ambulance attendants serving Preston Royal Infirmary have long been made aware of the part they are expected to play in the war of the roads, and their response has been instant and gratifying. Regular lecture-demonstrations in advanced ambulance aid are given to these workers, and, in an effort to bring them into even closer contact with the hospital, a direct radio link between the ambulance vehicles and the emergency department was established many years ago (Garden, 1962; Hall and Garden, 1967). This rewarding experiment has done more than anything else to ensure rapid attention for the seriously injured.

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As a result of the radio link, the ambulance men no longer feel isolated and ill at ease when confronted with difficult situations or unusual problems. They are at all times in direct radio contact with the hospital doctors, whom they have come to know personally, and to whom they are encouraged to appeal for help at any hour of the

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stressed, and it appears to me that humanity might have been better served if the expression ‘ like a fish out of water ’ had been supplanted by the less elegant simile ‘ like a man out of air ‘. However this may be, the hand of the first-aid worker, ambulance attendant, passer-by, or policeman trained to support the mandible, to

Fig. 6.

day or night. They also know that these doctors will welcome whatever observations they can bring concerning the circumstances of the accident, the amount of bleeding, the level of consciousness, and the patient’s general behaviour. When a motorist is trapped in his vehicle it is easy for the ambulance men to use the radio link for calling out the mobile emergency team. This team is provided with compact and easily carried equipment, and it has often been required to set up an intravenous infusion on the spot, or, on occasion, to give a short anaesthetic to ease the agony of removal from a crumpled vehicle. In the training programme arranged for the ambulance workers, every opportunity is taken to drive home the well-worn message that, with the exception of severe but quickly controllable bleeding, they must first and foremost rivet their attention on the airway. The loss of three litres of blood, they are told, can be replaced easily if need be, but the loss of three minutes of air is irreparable. The most expertly applied bandage or splint is then a waste of effort if the patient has been unable to breathe for this short but critical length of time. It is curious that this fundamental aspect of first-aid work should need to be so constantly

hook the tongue forwards, or to turn the unconscious patient on his side represents the hand of the doctor stretching all the way from the hospital to the roadside (Fig. 6). The war-time finding, that the simple transfer of a gravely wounded soldier from stretcher to operating table could cause an alarming fall in blood-pressure, still applies in civilian practice, and the ambulance attendants are reminded that gentleness in handling an injured patient, like reassurance, is a form of treatment in itself. At the hospital, the need for immediate, as opposed to early, treatment for road traffic casualties can be met in several ways. The parking problem now afflicting every hospital compound can be overcome by providing an emergency ambulance bay. A specially designed resuscitation trolley containing all the essential drugs and instruments for the management of a surgical emergency (Hall, 1972) enables intubation, blood transfusion, pleural drainage, or mechanical ventilation to be organized within minutes of the patient’s arrival. The ’ shadows ’ of the instruments on this trolley are painted in fluorescent red, and the absence of an instrument can then at once be detected by any member of the staff glancing in

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its direction. This avoids the embarrassing discovery in a respiratory crisis, where there is no time left for fumbling, that an essential piece of equipment is missing at the moment when it is most in need. In contrast to the chaos and confusion which greets a badly injured person unexpectedly arriving in the midst of a bustling casualty session, the radio warning that a patient in need of instant attention is on his way to hospital, enables the reception area to be cleared and an adequate number of doctors and nurses to be assembled well in advance of the patient’s arrival. This quietly waiting and fully equipped team can then proceed with its work in an orderly way. In these relaxed conditions there is ample time to consult the ambulance attendants and to record the information which they bring. In this context, we become increasingly fond of inflicting special forms on those whose hands are already over-occupied and whose attention is wholly absorbed in the emergency treatment of seriously injured people, and I dislike the suggestion that this imposition should now be extended to the ambulance crews. A difficult and lengthy questionnaire has been proposed for these men, but it is unreasonable to expect them to answer a host of questions when they would be better occupied by attending to the airway, or struggling to control external haemorrhage in conditions of personal danger, fog, snow, ice, darkness, or driving rain. And is it really necessary for the ambulance workers to discover the patient’s name, age, address, and occupation? This is not to deny that every scrap of information that the ambulancemen can bring to the hospital doctor is of great importance, and they should certainly be given weatherproof cards on which to scribble whatever observations they care to make. But it is unrealistic to insist that they should answer the unanswerable question: ‘ Have you treated the “shock”? ’ SHOCK How does one treat ‘ shock ‘, what do we mean by this word, and how can we possibly reconcile the conflicting newspaper reports that one motorist taken to hospital after a road accident was found to be suffering only from ‘ shock ’ and allowed to go home, whereas another died from ‘ shock ‘? We must clarify our use of this emotive word, on which so many of our arguments are hung and so much of our teaching is based. The word ‘ shock ’ is generally taken to imply that some evil influence is at work after injury, but the immediate response of the body to

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trauma suggests that an exactly opposite influence is being exerted. In any event, it is improbable that Nature, the greatest physician of us all, would deliberately add insult to injury by producing disturbances intended to magnify the results of trauma. Some of the known phenomena of ‘ shock ’ are at tirst life-saving in their effect, and this beneficial action is most easily seen when blood-loss is countered by widespread vasoconstriction-with the miraculous exception of the circulation to the heart and brain. Many writers have shown that some of the electrolytic, metabolic, and hormonal responses to injury are likewise defence mechanisms which may be essential to survival, and if the overall picture presented by these mechanisms is to be described as ‘ shock ‘, it is high time that we changed our attitude to this word, or, better still, that we changed the word itself. We should welcome rather than fear the onset of ‘ shock ‘. and it is an insult to Nature to use this forbidding term in describing the heroic train of events which she sets in motion to ensure that the seriously injured are given every chance to live. A warmer expression is needed to define these events, and I believe that accident surgery would be enriched if we could entirely dismiss the word ‘ shock ’ from our vocabulary. We should then at least be spared the constantly repeated injunction : ‘ First treat the shock ‘. This meaningless directive suggests to both lay and professional workers that they should try to reverse the immediate responses of the body to trauma instead of following Nature’s lead by encouraging these responses until the injuryand not the ‘ shock ‘-can be treated. In some ways, we have already learned to do this. The pale shivering patient with a rapid thready pulse is no longer subjected to the lethal ‘ shock cradle ’ which used to be the standard and often the only form of resuscitation not so many years ago (Fig. 7). Instead, we now emulate Nature when we seek to maintain contraction of the skin capillaries and to reduce the demand for oxygen, by keeping the patient cool. As we know, it is folly to encourage these early responses to trauma for any length of time. They are the last possible defences that Nature is able to erect in her struggle to maintain life, and when they can be made to disappear by early and vigorous treatment of the underlying trauma, the defence mechanisms probably do little permanent harm. When adequate treatment does not come to the rescue in time, and these mechanisms are allowed to continue for several hours,

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the even more bemusing state of ‘ contra-shock ’ will supervene. We also know that continued vasoconstriction leads to irreversible damage to the oxygenhungry liver, kidneys, and anterior part of the

Fig. 7.-Electrically-heated

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millions of years. J. B. S. Haldane said: ‘ Nature may be defined as That which does not accept excuses ‘, and it is certainly true that the laws of Nature, unlike the laws of man, can never be broken with impunity.

‘ shock cradle ’

at

one time in everyday use.

pituitary gland. What we do not know is how many seriously injured patients would survive long enough to develop these complications if Nature did not provide the spontaneous reaction to trauma that we now ungratefully describe as ‘ shock ‘. Indeed, we are entitled to ask, Would any road accident victim who suffers serious haemorrhage live for more than a minute or two if he did not also ‘ suffer ’ from ‘ shock ‘? It would seem fitting, therefore, to regard ‘ shock ’ as a friendly and indispensable ally in the fight for survival, rather than a fearsome and unwelcome reaction to injury.

It is not without significance that we never dare to write this word without depicting its first letter in capital form. In doing so we bow, consciously or otherwise, to the belief that behind the mathematical precision and unerring complexity of it all, there is a Guiding Hand. So, whatever our individual interpretation of Nature may be, we should use this word with reverence and understanding; and we should never cease to be grateful for the natural tendency of our wounds to heal and our fractures to unite.

NATURE

In the high-velocity road traffic accidents of today, head injuries are responsible for the greatest number of deaths. In the Heidelberg Clinic (Giigler, 1965) 70.26 per cent of 269 fatal road accidents were caused by injury to the head (Fig. 8), and Sevitt (1968) stated that tentorial herniation was the cause of death in 34 per cent of 250 road accident fatalities. Although tentorial herniation is a secondary event-a complication of injury, and, as such,

The word Nature, which I have used so freely, must also be defined. What does this word signify, and what right have we to side-step the explanation of surgical phenomena that we do not understand, by hiding behind its comforting faGade? So far as accident surgery is concerned, I regard Nature as the present stage in an evolutionary process trying to counteract the effects of injury, and still striving to reach perfection after

ROAD ACCIDENT Head injuries

FATALITIES

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theoretically preventable-extradural haemorrhage continues to be a recurring source of great distress to us all. Try as we may, this ‘ thief in the night ’ (Potter, 1961) repeatedly finds the chinks in our armour.

Angiography and ultrasonic probing by echo-encephalography are already available in the investigation of head injuries, and attempts are being made to monitor the varying pressures in different parts of the brain by electronic -

Head injuries Spinal injuries m

5 = 1.86 %

Chest injuries _ Abdominal

15 = 5.58%

injuries m

Pelvic injuries

m

9 = 3.35% 2 = 0.75 ?b

Multiple causes _

13 = 4.84 “,b

Shock m F;t embolism (g$c?;;;

8 = 2.98 9/,

_

12 = 4.46%

=Y&“;;

m

Tetanus

m 1 = 0.37 T/o

Gas gangrene Primary

B

189 = 70.26%

4 = 1.49 76

1 = 0.37 I;;,

disease _

Fi,. 8.-Causes of death in 269 of-Geigy Pharmaceuticals.)

10 = 3.70 %

fatal road accidents (from the records of the Heidelberg Clinic). (By cowtesy

We are still content to teach that a boggy swelling overlying a fracture of the cranial vault, a dilated pupil, and weakness of the contralateral limbs are the signs of extradural haemorrhage. But these are not really the signs of extradural haemorrhage. They are the signs of impending death. And if we are to prevent the allegedly preventable complication of tentorial herniation, we must learn to foresee its onset long before the fixed pupil and its attendant signs sound the alarm that only minutes remain in which to decompress the skull. This means that our vigilance over patients with head injury should be greatly intensified, and it is here, in particular, that vigilance must begin at the roadside. The ambulance attendants should be constantly urged to recount their observations of a patient with head injury to the hospital doctors. The accident surgeon confronted with an unconscious patient, and aware that a lucid interval has occurred, is in a much better position to keep one step ahead of tentorial hemiation, than when this information is unavailable or withheld. Routine nursing reports of the temperature, pulse, respiration rate, blood-pressure, and the patient’s response to stimuli, at quarter- or halfhourly intervals, are good-but they are not good enough.

techniques deriving from space research. But these high-flying methods of investigation are still under trial, and for the time being we must continue to rely on clinical findings. The more precisely these findings can be measured, the more life-saving they will be. The level of consciousness can be gauged against a carefully graduated set of stimuli, and experiments are now in hand to devise some form of pupillometer to replace the vague impressions that one pupil may be slightly more dilated than it was half an hour previously, or that contraction is perhaps slightly more sluggish in one pupil, irrespective of which eye is illuminated. Other experiments are being undertaken to confirm or refute the impression that one arm or leg is falling away a little more freely than its fellow, when it is lifted and released. In the absence of a base-line and accurate recording methods, the patient’s response to stimuli, the behaviour of his pupils, or the degree of lateralized muscular weakness are blunderbuss observations, and we would do well to recall Lord Kelvin’s (1889) statement: ‘ When you can measure what you are speaking about and express it in numbers, you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind.’ Precise methods

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of measurement are urgently needed in the management of cerebral trauma, and there is here a yawning opportunity for worthwhile research.

of chest injuries (Salpekar,

Journal

Multiple Injuries (T&e Z). Here, the blood-gases impressions or hoped that this practical help.

Chest injuries Injury of the chest is the second commonest cause of death after road accidents. Chest injuries vary from the breath-catching fracture of a single rib (in which the pain can be dismissed in a few seconds by the application of an ethyl chloride or Skefron spray) to the dangerous crushing injury which demands the full resources of an intensive care or multiple injuries unit. It is thus important that the accident surgeon should quickly recognize those injuries of the chest which are likely to threaten life. Table /.-Classification

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Unit at Preston Royal Infirmary again, accurate measurement of takes precedence over clinical radiographic shadows, and it is classification will prove to be of

Multiple causes In the Heidelberg studies, the third largest group of road accident fatalities is contained within the section labelled ‘ multiple causes ‘. But this is a sloppy label, and until we can say which of these causes, or which combination of these causes, proved to be mortal, this label will remain as an admission of our inability to measure the effects of trauma in a scientific way.

1970) Grade

I

Mechanical

Few rib fractures

II

Multiple ribs

fracture

Pneumothorax haemothorax Parenchymal

Blood-gases

Unaffected

Pao, 80-I 00 mm Hg Pace, 35-45 mm Hg (Normal)

Ill

’ Stove-in

or

IV

’ chest

Pneumothorax haemothorax

and

Segmental atelectasis

Moderate degree of pulmonary contusion

Pulmonary oedema with 48-72 hours

Pulmonary oedema within 24 hours

70-80 mm Hg 50 mm Hg (COP retention with mild hypoxia)

60-80 mm Hg 45-55 mm Hg (Progressive CO2 retention with hypoxia)

Patients suffering from intrathoracic injury often show a curious skin discoloration of the pectoral regions, the shoulders, and the sides of the neck (Salpekar, 1970). This colour is wholly different from the cyanosis of chronic respiratory and cardiac states or traumatic asphyxia, and is difficult both to describe and to photograph faithfully. It most closely resembles a lilac or heliotrope hue, and unlike the staining of traumatic asphyxia it disappears as soon as pulmonary ventilation is re-established. It is unfortunate that a suitable classification of chest injuries has not been available for the guidance of the accident surgeon in the past, but Salpekar (1970) has now proposed a subdivision of these injuries, based on his experience of 110 crushing injuries of the thorax treated in the

Bilateral, often tension, pneumothorax and haemothorax Rib fracture rare Bilateral severe pulmonary contusion and intra-alveolar haemorrhage Pulmonary oedema within 6 hours 30-40 mm Hg low 50-60 mm Hg high (Massive physiological ’ shunt ‘)

Fat embolism This ill-understood condition emerges hard on the heels of ‘ multiple causes’ as the fourth most common cause of death after road accidents. Great confusion surrounds this subject. Many surgeons report that it is rarely seen. Others, alive to its possibility, recognize its signs and symptoms time and time again. The effects of fat embolism-if it is fat, and if it is embolism-vary widely in their intensity. The behaviour of a young motor-cyclist with a simple fracture of the femoral shaft, who becomes delirious for several hours on the second or third night after his admission to hospital, is usually attributed to the frustrating immobility imposed on a recently active subject. But careful examination in the light of dawn often reveals the tell-tale

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petechiae of a transitory fat embolic syndrome. On the other hand, this syndrome can be far from transitory, and the deposition of fat-staining globules or debris in the lungs and brain can frequently lead to death. I have long suspected that a patient who displays a plentiful crop of petechiae is more likely to recover than one in whom the outward signs of this complication are absent or difficult to see. To check this suspicion, the records of 44 patients treated for fat embolism at Preston Infirmary were recently reviewed. This showed that petechiae were plentiful and easily seen in 32 patients, of whom 4 died, whereas 10 out of 12 patients died when petechiae were few or absent, and the diagnosis was made on the biochemical findings. ‘The survival periods for those who died ranged between 5 and 15 days. When fat embolism does occur, therefore, a shower of petechiae may be a more welcome finding than at first appears. The analogy can here be drawn with the relatively benign nature of a cancer which comes to meet the surgeon, compared with the greater malignancy of a new growth which buries itself deeply in the surrounding tissues. I have never been able to believe that the fatstaining particles which choke the lung capillaries come from the marrow of a fractured bone, and I cannot understand why these particles take so long to reach the pulmonary circulation nor how they bypass the vascular filter of the lungs to reach the arterioles and capillaries of the brain in such profusion. It has seemed to me rather that this is a general manifestation of trauma in which dead cells and their products, fibrin, platelet, or red-cell aggregates find their way into the systemic circulation. Many of the disturbances of trauma are known to have a common origin in tissue anoxia, and it would be unwise to overlook the possibility that other disturbances-fat embolism included-in which the cause has yet to be identified, may also result from the effects of oxygen deprivation on the individual cell. It is, however, certain that we now stand only in the porchway of that storehouse of knowledge which holds the answers to the manifold problems of trauma. Much remains to be done, and complacency is a poor companion for the accident surgeon. THE FUTURE Although there is some excuse for believing that our present methods of treating the injured are the best that have ever been, it would be arrogant to think that they are the best that will ever be. Those who present their new-found techniques as

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the ultimate in treatment-and there are many such-should bear in mind that the sum of human knowledge is now said to be doubling every five years, and, if the history of our craft is any guide, that the surgical miracles of today are likely to be the ridicules of tomorrow. It would be more seemly, therefore, to offer any new method of dealing with some particular problem in the management of trauma as an additional, rather than the top, rung of the ladder leading to the solution of the problem. To add another rung is to stimulate further effort. To skip a number of rungs and to place the top one in position, is to discourage further effort until such time as the supporting steps have been found to be missing. In the many ladders leading to improvement in the care of the injured which this century has seen, I doubt if the final rung has ever been discovered. It is thus essential that we should take a fresh look at our day-to-day routines and see whether the work that we do could not be done in a better way. This means that every statement that we make and every method of treatment that we advise should be exposed to the harsh searchlights of proof and counter-proof. Few contributions to the literature of accident surgery can survive the interjection of the query ‘ What proof have you of this? ’ at the end of every sentence, and it is a revealing exercise to apply this simple question to all that we say or read. If the editors of our surgical journals insisted that their contributors should furnish verifiable evidence for all that they submitted for publication, the present Niagara of medical writing would shrink overnight to the size of a mountain stream. The treatment of those who fall by the wayside in this war of the roads is thus more likely to be improved by a constant bombardment of questions than by the smug assumption that our present methods of treatment are satisfactory. Unlike our conclusions, our questions are in no way inhibited by the need for supportive evidence. We may ask what we will, and it is this unfettered liberty of thought which makes the pursuit of new knowledge so attractive and exciting. It is not true that the gift of scientific enquiry is given only to a few. We are all capable of asking questions, and if more and more of us could be persuaded to do just this, the ‘ right ’ question would be more and more certain to emerge. In the light of some of the questions now being asked, however, I wonder whether we have taken the wrong turning and lost our way in our forest of perplexities-or are we simply failing to see the wood for the trees?

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Oxygen and its carrier haemoglobin are the twin pillars of life, and the need to bring oxygen to the lungs and from the lungs to every single cell in the body seems to be what it is all about. But this implies that little else matters, and is clearly an over-simplification. Even in the unlikely situation where respiratory dysfunction is at once corrected and the blood-volume is immediately restored after injury, there is no guarantee that a patient treated in this way will then escape complications or death. Many other factors are at work, and we must probe ever more deeply into the nature and effect of what may most simply be described as the ’ poisons ’ of trauma-histamine, myoglobin, polypeptides, tissue metabolites, or whatever they may be called-which invade the general circulation from crushed, bruised, or broken tissues. The modern research workers in the field of trauma increasingly concern themselves with the micro-circulation, with the ‘ micro-respiration ‘, and with micro-measurements of unbelievable precision. They are now peering into the cell itself, and fascinating hypotheses are beginning to take shape. These investigators form the intelligence service in the war of the roads, and it is by their exertions that the enemy will be forced to surrender the secrets of metabolic response to trauma and multiple organ failure. Like so many mysteries, those secrets, which have held us at bay for so long, will almost certainly prove to be annoyingly simple when they are revealed. The present signs are that the expected disclosures will do no more than underline the basic need to ensure that not only the patient, but every single cell in his body must be given ‘ a breath of fresh air ‘. If, then, we can think of the single-celled amoeba as a little fish, my earlier objection to the simile ‘ like a fish out of water ’ is at once ‘ like an destroyed, and the new expression, amoeba out of water ‘, becomes a more practical analogy. When the energy-producing oxygen is extracted from the water in which the amoeba swims, it will disintegrate and die. When the oxygen is removed from the extracellular fluid in which every human cell is bathed, it, too, will disintegrate and die. And the more highly specialized the cell, the more quickly will it succumb to anoxia. So, the sooner that both the amoeba and the human cell are returned to their oxygen-rich pericellular fluid, the less likely are they to suffer harm or to perish. In the present state of our knowledge, the need for oxygen-not merely in the inspired air but in every recess of the micro-circulation-should

Injury:

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be our constant battle-cry. The ultra-sensitive measuring instruments now at our disposal show that we have less time to meet this need than we think, and Cole (1972) has recently gone as far as to say that patients with multiple fractures, because they consistently show low Paoz levels

Fig. 9.-Alan F.R.C.S.

Ruscoe Clarke, M.B.E., M.B. (Lond.),

even in the absence of thoracic injury, should be given oxygen continuously by mask or nasal catheter in the ambulance and throughout the first week in hospital. This may not be altogether good advice if pure oxygen is given by mask for any length of time. Paradoxically, oxygen breathed in 100 per cent concentration can be just as harmful as the hypoxaemia that it is intended to counteract. The medical aspects of trauma have long usurped the crude mechanical considerations of the orthopaedic surgeon, and the Birmingham Accident Hospital staked an early claim to this approach. The book Modern Trends in Accident Surgery and Medicine, published in 1959 and edited by Ruscoe Clarke, Badger, and Sevitt, was seen-in its title alone-as an important turning-point in the battle to improve the care of the injured. The words and medicine undoubtedly jolted even those who did not take the trouble to read the book. The second edition of this volume under the chairmanship of P. S. London retained the same heading, and it is tempting to speculate how long it will be before the words surgery and medicine are transposed in future editions of this work.

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123

In this rambling discourse, I have posed many questions, and I have sought to stress the importance of the immediate as opposed to the early care of the injured. I have also tried to indicate the need to restore ‘ the pistoned bellows of the lungs and diaphragm ’ (Keith, 1926) to their full efficiency, and the volume, quality, and oxygen tension of the circulating blood to their normal value, at the earliest possible moment. In doing so, I have merely reiterated the principles laid down by Ruscoe Clarke (Fig. 9), which the Birmingham Accident Hospital team have continued to develop so well; but if I have succeeded in stimulating at least one more of you to follow Clarke’s example to think, to measure, to record, and in this way to uncover a fragment of new knowledge in our struggle to improve the care of the injured, I shall have kept faith with that forward-looking man in whose memory we are met today.

REFERENCES

CAIRNS. H. (1941). ‘ Head iniuries in motor-cyclists. The importance bf t he cra& helmet ‘, Br. mei. J., 2, 465.

COLE, W. G. (1972), ‘Respiratory sequels to nonthoracic injur) ‘, Luncet, 1,555. DAWSON, R. F. F. (1971), Current Costs of Road Accidents in Great Britain. Road Research Laboratory Report, LR 396,7. Requests for reprints should be addressed

Preston, PRI 6PS.

GARDEN,R. S. (1962), ’ Multiple injuries ‘, in Modern Trends in Orthopaedics, 3 (ed. CLARK, J. M. P.), p. 58. London: Butterworths. GIBSON,R. Myles (1972), personal communication. G&LER, E. (1965), Road Accidents. Documenta Geigy, Series Chirurgica No. 5. English translation, p. 31, Basle: Geigy. HALDANE,J. B. S., Reported by CLARK, R. (1968), The Life

and

Work

of J. B. S. Haldane,

D. 59. _

London: Hodder & Sioughton. HALL. M. H. (1972). ‘ A resuscitation trollev for the emergency and accident department ‘, Ini&, 3,203. -and GARDEN, R. S. (1967), ‘ Radio communication and the emergency department ‘, Br. med. J., 1,296. KEITH, A. (1926), Engines of the Human Body. p. 130. London: Williams & Norgate. KELVIN, W. (Lord Kelvin) (1889), Popular Lectures and Addresses, vol. 1, p. 73. London: Macmillan. after head LEWIN. Walpole (1968). ‘ Rehabilitation injury ‘, Bi. med. J., 1, 465, 470. PALFREY, W. J. H. (1970), Accidents 1970, p. 2. Lancashire Constabulary Annual Report. POTTER,J. M. (1961), The Practical Management of Head Injuries, p. 1. London : Lloyd-Luke. SALPEKAR,P. D. (1970), ‘ The crushed chest injury. Its physiology and classification ‘, Congressus Anaesthesiologicus Europaeus, Prague. Abstract 69103. SEDDON,Sir Herbert (1964), ‘ Volkmann’s ischaemia ‘, Br. med. J., 1, 192.

SEVITT, S. (1968), ‘ Fatal road accidents. Injuries, complications, and causes of death in 250 subjects ‘, Br. J. Surg., 55,48 1.

to:-R. S. Garden, Esq., M.B., M.Ch.Orth., F.R.C.S., F.R.C.S.(Edin.),The Royal Infirmary,