The Trauma Problem Overview And History

Chapter 1 Eugene Sherry Ch head

The trauma problem

Section I - Conflict and glory-the human saga (a philosophical aside) A

Introduction

A

Great works and great surgeons

A

Great wars

A

Future times

Section II - Epidemiology A

General principles

A

Investigating trauma

A

Steps in study design, implementation and statistical tests

A

Meta-analysis

A

Overview of trauma epidemiology in the USA

A

Trauma in UK, Australia, Europe, Singapore and Developing World

A

Prevention

Section I - Conflict and glory-the human saga (a philosophical aside)

A

Introduction

The Human Saga is one of conflict and occasional glory1. It seems the more we know about this world the more meaningless it appears2,3,4. There is conflict with the environment (fires, floods5, the workplace, pestilence, crocodiles (Fig. 1.1), beasts with hoofs and in motor vehicles6 (Fig. 1.2), foreboding waters and lands, rock climbing, rowing and marlin fishing) with others (wars, battles, fights, sport) and with oneself (intellectual challenges, self doubt and loss of confidence).7,8 In major conflict, War, the victor (and so the major player and writer of history) is the one who inflicts the most injuries and recovers fastest from injury received. 9,10 Many of our cultural and artistic 1

Cuchulain, the legendary Celtic warrior and son of the Irish god Lugh, was feared in life and certain death. King Conor gave him his own chariot and spears. In his last battle when mortally wounded he tied himself to a tree so as to remain upright and to continue to strike fear into the heart of the enemy only prepared to approach after a raven rested on his slumped shoulder. His stature stands in the window of the Post Office, O'Connel Street, Dublin. 2 George Bernard Shaw lampooned our obsession with guns and munitions in the character of Andrew Undershaft, millionaire arms dealer, in his play, Major Barbara. He saw in guns and gunpowder the power to change society. “Well, scrap it….That is what is wrong with the world at present. It scraps its obsolete steam engines….but it won’t scrap its old prejudices…moralities…religions..political constitutions.. If your old religions broke down yesterday.. get a newer and better one for tomorrow.” 3 Dennis Sciama has said "The universe in fact is a botched job, but I suppose we shall have to make the best of it..." W T Sullivan III The Clash of the Cosmologies Book review SCIENCE 1997 275 p1275-6 4 The essential theme of this book. The Blind Watchmaker: Why Evidence of Evolution Reveals Universe without Design.1996 Richard Dawkins WW Norton & Co 5 Too much water (floods) in Southern China in August,1998, have affected over 200 million people whilst too little (drought) in Karachi have thrown the city into chaos. 6 CJL Murray AD Lopez 1996 Evidence-Based Health Policy-Lessons from the global Burden of Disease Study Science 274 740-43 7 Man has a primitive biological need to hunt, fight and to use tools from - E Sherry 1998 Chap 1 p. 8 Oxford Handbook of Sports Medicine OUP Oxford 8 “…it is a lack of confidence, more than anything else, that kills a civilization. We can destroy ourselves by cynicism and disllusion, just as effectively as by bombs.” Kenneth Clark.Civilisation.1969 p347 BBC Books, London. 9 “Unless we insist on denying it, our future, like that of the last Easter Islanders, may belong to the men with bloodied hands”. John Keegan 1993 A History of War p392 Hutchinson London 10 “…Mates riddled to dog meat wholesale. Men screaming like stallions. Blood and shit blowing out of them in front” from Les Murray 1998 Fredy Neptune p31 lns 17-19 Griffin Press Potts Point

endeavours are centred around these events.11 We place great value on the sacrifice required and have celebrated it in the psalms of the Old testament and in the Catholic Mass.12 The great German Warrior and Writer, Ernst Junger celebrated war in his work as "our dream of greatness, power and glory... there is no lovelier death in the world"13. Any great civilization (and at this time it is the American) depends upon a strong military14 (as well as an emphasis on the individual and democracy). Such behaviour does not change with age or with the Ages15. We seem to keep forgetting that altruism pays (biologically and morally)16 although it has been said that pride and hatred not only invigorate the soul (while love and humility enfeeble it, Hume), but may well act as the engines of scientific progress.17 Hence the critical role of the trauma /military surgeon(the

11

Picasso’s Guernica depicts the horror of the Nazi bombing of Spain during the Spanish Civil War Igor Stravinsky’s work, Symphony of the Psalms, described as “one of the most extraordinary accomplishments in western music of this century in its suspension of time in static adoration and incantory contemplation” gives the impression of being inspired by a harsh, strong feeling that has grown out of the anguish of mankind, punctuated by occasional lighting falshes revealing the countenance of Jehovah. Robert Siobham:Stravinsky,Paris,1959 13 Ernst Junger 1929 The Storm of Steel Charto and Windus/Constable and Cpy Ltd London p1 14 In the US, the Military Effort, or Department of Defence, drives much of the scientific and academic basic research WmA Wulf Balancing the Research Portfolio Editorial Science 1998 281 p1803 15 “Men never grow up. Male maturity is a myth. We are just a bunch of no-good, grossly incompetent human beings who throughout history have been pretending to evolve from gangling adolescence into hardnosed “men”….men are obsessive, sexually insecure, blubbering egomaniacs, and most of the stuff about masculinity that men have been peddling for centuries has been sheer nonsense…Now, with a clear conscience, you can invite your mates around, crack a slab of beer, sit down and watch the footie, fart and belch, go and pee off the back verandah and spend hours telling really bad jokes about women with big jugs and recounting fantasies of breath-taking sexual prowess… ”Bruce Elder. Men Behaving Sadly. Sydney Morning Herald Newspaper. p 7s Aug 8,1998. 16 Reciprocal altruism (including to strangers) has been mathematically modeled to show that it makes evolutionary sense. MA Nowak K Sigmund 1998 Evolution of indirect reciprocity by image scoring Nature 393 573-577 17 W Gratzer Anyone for tenets.?1998 Nature 394 843-4 12

fixer of their injuries and ambitions)in determining the final outcome.1819 For this reason, leaders place great store upon their military surgeons.20 The spoils of sort victory are land, gold and (unlimited) reproductive rights (sex)21; (whose role is it protect these spoils?22). A consideration of Great Works, Great Surgeons and Great Wars will illustrate this. The great medical writings of the past have, as of necessity, been about injury. Great, as they have stood the test of time by elevating generations of physicians to feats of clinical judgment, treatment and insight. Such works represent the clinical experience and wisdom of their authors gained from huge clinical exposure and the determination to record it (John Hunter, perhaps the greatest surgeon of all time, had great military experience, monumental scientific insight but was a lousy writer and speaker with a terrible temper and no time for manners-the latter cost him his life from a myocardial infarction after an argument and the former almost his reputation after his death. Jeremy Foote wrote his biography in which he all but destroyed Hunter’s reputation for nearly 50 years).

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“Wounding and being wounded are the dark premises of healing: it is they that make the medical profession possible, and indeed a necessity for human experience. For this existence may be conceived as that of a wounding and vulnerable being who can also heal”. C Kerenyi 1960 Archetypical Images of the Physicians’s Existence. Thames and Hudson. London 19 A piece of Greek pottery from the second century BC a statement written by two brothers who denied beating up a third brother by saying “the wound(trauma)that you have we ain’t done it…”. John H Davis 1996 Chap 1 in TRAUMA 3rd Ed Eds DV Feliciano, EE Moore, KL Mattox. Appleton & Lange, Stamford, Connecticut 20 Napoleon bequeathed 100,000 francs to his military surgeon, Dominque Jean Larrey and stated “He is the most virtuous man I have ever known”. 21 Biologically, youth and fertility is favoured in females but “testosterone-charged” dominance in males. Increased testosterone levels increases infidelity, violence and divorce. A Booth J Dabbs 1993 Testosterone and men’s marriages. Social Forces 72 463-477 22 Feminization is favoured…producing a partner who is more honest,cooperative and a better father.DI Perret et al Effects of sexual dimorphism on facial characteristics.Nature 1998 394 884-887

A

Great works and great surgeons

B

Ancient times

The Edwin Smith Papyrus, written between 3000 and 1600BC,describes 48 cases of trauma from the head to the foot.23Probably the work of the great Imhotep: physician, architect, God and chief minister to King Zoser c. 2800BC. The principles so enshrined are still pertinent today.24 The Vedas, the Sanskrit sacred books were written 3500-1000BC in Ancient India. The oldest, Rig Veda, considered the early physicians to be divine, capable of curing paralyses and shattered limbs. The Epic Era (1000-600BC) with surgeons at work on the battlefield produced the great work, the Ayurveda Susruta, the great Indian surgical sage from around 800BC, produced the Susruta Samhita.25 Hua T’o was the most famous Chinese surgeon (born around 190AD) who was worshipped in temples as the god of surgery. Famous texts include Nei Ching (Canon of Medicine) by Yu Hsiung about 2600BC which described debridement of dirty ulcers,

23

John H Davis 1996 Chap 1 in TRAUMA 3rd Ed Eds DV Feliciano, EE Moore,KL Mattox. Appleton & Lange, Stamford, Connecticut 24 In 1862 tomb robbers at Thebes found a papyrus which they sold to Edwin Smith, an American Egyptologist. It is the oldest Afro-Asian surgical treatise with careful clinical observations of injuries and treatment. It is not the original but a 1,000 year old copy. It can be viewed at the New York Academy of Medicine. Injuries are classified:(1) Favorable prognosis, “an ailment which I will treat”;(2)May go either way, “an ailment with which I well contend”;(3)A hopeless case, Spritzfall, “an ailment not to be treated”. Case 3 was a compound skull fracture, to be treated; Case 5 a depressed fracture, to be left; Case 8 a hemiplegia; Case 31 is an excellent description of quadriplegia. From D LeVay 1990 Chap One The History of Orthopaedics An invaluable source of information for this chapter. The Parthenon Publishing Group New Jersey, USA 25 It deals with the scope and requirements of good surgical technique-the surgeon must be clean, nails short, well-mannered, and work in a clean OR which is also fumigated. The surgeon must use inspection, palpation, percussion and auscultation.

Chou Kung’s Medicine of Wounds (1200BC ) and one on Fractures and Wounds from the Imperial Medical College(founded 1076AD). In Japan, the first known surgical monograph was Chi-so-ki by Fukuyoshi (Showa Era,834-847AD),it was really a survey of Chinese surgery. During the AzuchiMomoyama Period(1569-1615,period of European viz. Dutch influence) Dosan Manase wrote the Keiteki-Shu with chapters on diseases of bone, wounds and the elderly. Later works were translations of European texts until the Yoka Hiroku (Theory and Practice of Medicine). Hippocrates (460BC-370BC) said that War was the only proper training for a surgeon. He came from the tradition of the natural philosophers-Thales, Pythagoras and Alcamaeon and established medicine as a separate profession. His writings comprise 60 books (including De Articularis-a masterful account of the treatment of fractures and dislocations) from 430BC to 330BC. He ran a private practice (worked for gain) and systematized medicine, established medical science and introduced proper independence and social standing for the physician (he was scathing about the adventurous and “marvelous” methods of charlatans). The Hippocratic bench, or scamnum, remained in orthopaedic practice for over 2,000 years. Until recently, generations of graduating doctors took the Hippocratic Oath (Appendix A). The Hellenistic Period (3-200BC),when the Greek academic and medical achievements spread to Asia, Alexandria and Rome, saw the work and writings of Celsus (25BC-50AD) He was an encyclodaedist not a physician and wrote about the cardinal signs of inflammation.

Rome produced no great science but the great Galen (129-199AD).He was influenced by the work of Hippocrates, gained his vast experience as a gladiatorial surgeon in the Pergamon arena in Asia Minor, is called ‘The Father of Sports medicine’ and was called to Rome by Marcus Aurelius where he had an enormous practice. His writings(over 500 of which 83 medical treatises have survived) dominated the theoretic basis of medicine for the next 1500 years. He was dogmatic, arrogant, seldom wrong, without followers but “the most influential writer of all time” .26,27 An original thinker he was celebrated for his careful and accurate observations. When he died, medical scientific enquiry is said to have ceased and the Dark Ages began28.

B

Middle Ages (fall of Rome-AD 476 to fall of Constantinople-AD 1453)

Paul of Aegina (625-690AD) and Apollonius were influenced by Hippocrates and worked in Alexandria. From the era of the Byzantine Era, the Christian Church Fathers assumed the care of crippled children and adults. Cosmo and Damien, the Patron Saints of Physicians and Surgeons were martyred by Diocletian in AD303, and are accredited with the first (and only) limb transplant, of a dead Moor’s limb to a patient after a cancerous one; done of course with the help of angels29. Medicine and religion began a long association. Saints are the heroes of Christianity serving as a source of inspiration to believers from their works. There are only 300 saints associated with various diseases26

Galen’s bust is no where to be found amongst the other Greats of Medicine on the wall in the Anatomy Dissecting rooms of the University of Sydney. This represents the reaction to his long domination of medical thought (teleological explanations for everything and use of the humoral theory of phlegm/blood/yellow bile/black bile) where in the Middle Ages he was quoted verbatim. His intellectual integrity has been resurrected on the front page of WorldOrtho, www.worthortho.com. I doubt if the Internet will last as long or be as influential. 27 A S Lyons 1979 p251 in Medicine An Illustrated History Eds AS Lyons and RJ Petrucelli Macmillan Melbourne 28 C Singer EA Underwood 1962 A Short History of Medicine 2nd Ed OUP 29 R Magee Saints in Surgery 1998 ANZ J Surg68 605-610

they may have been real or imaginary people, the legends of their deeds (based upon miracles by them or at their shrines of details of their martyrdom) fact or fantasy. Other healing saints include Blaise (throat disorders), Barbara (breast) and Erasmus (entrails). The Great Arab Tradition of Medicine, the medicine of later Greek antiquity, centred on the great Rhazes (850-932AD) and Avicenna (980-1036)30. The latter wrote his Quanum of Medicine. Moses Mainmonides wrote the Medical Aphorisms in 1497. Other texts worthy of mention are: Practica chirugiae by Roger of Palermo in 1180,said to be the first surgical text of Western Europe. During the Period of the Awakening (10th to 12th Centuries) was founded the great Universities, Hospitals and Medical Faculties of Salerno, Paris, Oxford, Bologna, Montpellier, Padua, the Faculty of the College de St Come in Paris. Great hospitals, derived from the Roman valetudinaria, were established in Baghdad (the Bimaristan AlAzudi in 981), London (St Bartholomew’s in 1123,St Thomas’s in 1200). Much of this change in attitude to the sick and injured (from the Roman times where hospitals31 were only for the wounded soldier) came from Christianity with a fostered sense of compassion for the sick and injured. At this time Henri de Mondeville (1260-1320) worked to avoid suppuration with an emphasis on simple cleanliness, Guy de Chauliac (1300-68) had surgery put into the hands of qualified surgeons rather than quacks and introduced traction for lower limb fractures.

30

Elgood says that Avicenna was one of the greatest men the world has seen. C Elgood 1951 A Medical History of Persia Cambridge University Press. 31 The Romans are said to have perfected trauma care and established trauma centres around the Roman Empire, called valetudinaria, built during the 1st and 2nd centuries AD. Roman legions had a regular medical corp.

B

Renaissance (1450-1600)

Ambroise Pare (1510-1590)was the most famous surgical figure of the 16th century in France who was said to have revolutionized the treatment of war wounds (army surgeon under Henri 4th and surgical adviser to several French Kings; noted the cleansing action of maggots on wounds, used windlass traction for femoral fractures and recognized cord compression in vertebral fractures) and saw in the modern era of prostheses and bracemaking. His great encyclopaedic work, Dix Livres de la Chirugie was written in French (not the conventional medical Latin) with a section on surgical anatomy, the use of ligatures and tourniquet and ended the use of boiling oil or cautery for amputation stumps. He was a humane man at a time when it was not a marked feature of military surgeon.32 He restored the status of the barber surgeons of France after his admission to the ancient surgical fraternity of the College of St. Come. Dominique Jean Larrey (1766-1842), Napoleon’s surgeon, who personally performed over 200 amputations in one 24 hour period during the Russian campaign, considered all aspects of trauma care(sanitation, food supplies, transport, training of personnel) of the wounded soldier. He introduced the “flying ambulance”, forerunner of the Red Cross (to rapidly remove the wounded from the battle field, previously left there until the day’s fighting ended), put the hospital as close to the front as possible to start wound surgery without delay and in the period of “wound shock” when there was some

32

He wrote of the expedition against Turin in 1537 “we entered the throng in the City….some were not yet dead; we heard them cry out under our horses’ feet………….There happened to come in an old soldier, who asked me if there were any possible means to cure them, I told him no; he presently approached them, and gently cut their throats without choler. Seeing this great cruelty, I told him he was a wicked man, he answered that he prayed to God that whensoever he should be in such a case, that he might find someone that would doe as much for him, to the end he might not miserably languish”. From The Apollogie and Treatise of Ambroise Pare, trans. Th. Johnson 1643,ed.Keynes G, Univ Chicago Press,1952.

analgesia and a lesser chance of post-amputation wound period sepsis and wrote about frost-bite, trench foot, scurvy, eye infections, and stomach tube feeding.33 Heinrich von Pfolspeund wrote Bundth-Ertznei in 1460;said to be the first book on trauma. He emphasized keeping wounds clean, not closing all wounds and hand washing. Hans von Gersdorff based his handbook, Das Feldbuch der Wundarzney, published in 1517 and the first with a lot of illustrations, some in colour, on his 40 year army experience.

B

The Scientific Revolution

The “Age of the Scientific Revolution” in the 17th Century saw the publication of William Harvey’s De Motu Cordis (which described blood circulation), intravenous injections and blood transfusions. The 18th century-Hales developed artificial ventilation and measured blood pressure, Black descried carbon dioxide in 1757,Cavendish hydrogen in 1766, Rutherford nitrogen in 1771 and Priestly and Scheele oxygen in 1771and AntoineLaurent Lavoisier described the process of respiration. Giovanni Batista Morgagni at Padua (later acknowledged by Virchow as the first pathologist) established the science of cellular pathology so finally discrediting humoral theories. But it was the insatiable and all-embracing intellectual enquiries of the great John Hunter (1728-1793 )(Fig. 1.3) which was to dominate surgical thinking from the 18th century until the present. A word about his urbane and humanist brother, William (171883), the most fashionable” man-midwife” of England, who channeled his younger brother 33

Albert Lyons The Nineteenth Century p513 Chap in Medicine An Illustrated History Eds AS Lyons and RJ Petrucelli Macmillan Melbourne

into anatomy and surgery early but fortunately was unable to temper his intellectual determination with soothing manners (though poor manners nearly undid the great Hunter). John Hunter collected over 65,000 (19,000 survived the bombing of London) specimens of plants and animals (Joseph Banks brought him a platypus from Australia) to illustrate the development of physiology and pathological processes, (establishing himself as an expert in comparative physiology and experimental morphology) trained the top surgeons and scientists of the day (Jenner, Astley Cooper, John Abernethy, including the Americans of the Civil War Fame-John Morgan, founder of the first American Medical School at the University of Pennsylvania and William Shippen) and wrote A Treatise on the Blood, Inflammation, and Gunshot Wounds (one of the best texts on trauma). Lorenz Heister (1683-1758), Professor of Medicine and Surgery at the Julius University of Helmsted, held a vast library of 12,000 volumes and 500 instruments Sir John Pringle (1707-82) ,Surgeon General of the British Army was the founder of military medicine, initiated the idea of the Red Cross34, recognized the need for good ventilation in ship hulks and military prisons and realized that jail and hospital fever were the same thing, Russian Surgeon, Reyher, from the Franco-Prussian War(1870-74) reported his success with the antiseptic management and debridement of wounds in reducing mortality in 1874.

B

34

Nursing care

In the Battle of Dettingen,1743,the French and English combatants agreed to make hospitals sanctuaries for the wounded. This concept was ratified by the Geneva Convention of 1864.

Established by Florence Nightingale from her experiences during the Crimean War(185356).She established sanitation, food services, clean water, laundry, cleaning and statistical data collection and medical records.

B

The Period of Colonial Expansion

The Period of Colonial Expansion by the major powers (17th to 19th centuries) saw the need for surgical and trauma care as far away as Australia. There were 9 medical men on the First(British) Fleet which set sail on 13 May,1788, to Australia. Remarkably only one of 121 marines and 24 of 775 convicts died on the way out to establish Australia. Murderers and sodomists were to be sent to New Zealand to be eaten by cannibals.35 Doctors such as Kevin I. Doherty (1842-1905), transported from Ireland whilst a medical student for “treason-felony”, contributed hugely to the medical and civic development of the Colony. William Balmain, Principal Surgeon of the Colony from 1796,extracted a native’s spear from the neck of Governor Phillip on 7 Sept.,1790. Problems of 19th Century Australia included drowning, horse riding accidents, gunshot wounds, emergency childbirth, snakebites against a background of a widely dispersed population, long distances, extremes of hot and cold and a hostile environment36. The 19th Century was a time of social upheaval (French Revolution)and intellectual development (Virchow’s Cellular Pathology in 1860, introduction of anaesthesia 1847 by WTG Morton and antiseptic surgery in 1867 with the work of Pasteur and Lister). 35

N Dan Chap One The Medical Men of the First Fleet, Chap One in: Australia’s Quest for Colonial Health 1983 J Pearn C O’Carrigan Eds The Univ Printery Univ Queensland 36 J Pearn 1998 A history of first aid in Australia: the evolution of prehospital care MJA168 p38-41

B

Modern times

The 20th Century with major conflict of the World Wars necessitated the refinement of trauma care with understanding of metabolic care, fluid therapy, treatment of haemorrhagic shock, use of antibiotics, resuscitation, helicopter evacuation (use of MASH units in Korean War, Da Nang lung in Vietnam), electronic monitoring of patients and refined anaesthetic services. Governments saw the virtue and likely return from huge investments in basic scientific and medical research (National Institutes of Health in the USA).

A

Great wars

Early weapons were: the hand held as a fist (Bronowsky saw the development of the hand as the focus of evolution and civilization), clubs, stones, slingshot, bow and arrow (40003000BC), armour (400AD), crossbow (1300AD); later came gunpowder (probably Chinese invention, used At Battle of Crecy in AD 1346) The need for trauma services parallels the development of weapons of mass destruction. Surgery was equated with the treatment of war wounds. Gunpowder was marked by the first use of a cannon at the Battle of Crecy in 1346.Treatment was often carried out in Central Europe by unqualified paramedics (battle hanger-ons, a type of medical underclass).

B

The American Civil War (1861-5)

Probably the bloodiest war ever fought with disorganized, chaotic and ignoble medical services provided37. Two percent of the US population (of 3M) perished in the conflict (more died from disease than injury; the Union Army lost 110,070 (plus 249,458 from disease); the Confederates 94,000 (plus 150,000 from disease)38. The previous lessons of A Pare of 1545 were forgotten (generals avoided having medical supply wagons), the flying ambulance of Larrey was ignored at the outbreak, as were the nursing standards established by Florence Nightingale (Clara Barton, recruited nurses for the Medical Corps; later founded the American Red Cross), sterile techniques suggested by Oliver Wendell Holmes were not applied, secondary haemorrhage from infection was common, hospital acquired infections were rampant, 75% operations were amputations39 (1520%mortality for upper limb; 80% for thigh-similar figures to those reported by Pare in the 16th century). There was some progress in the sue of antiseptics with bromine reducing the mortality of hospital gangrene from 43.3 to 2.6% and many advances in orthopaedic management of injuries such as: Bucks Traction, use of plaster splints, open treatment of contaminated wounds, the development of specialty orthopaedic and prosthetic hospitals, early open reduction of fractures(predating x rays discovered in 1865 and the work of A Lane),shell fragment extraction, excisional arthroplasties, and refinement of amputations. J Kuz and B Bengtson, two young American Surgeons, have compiled a splendid atlas of these injuries; paying tribute to the brave soldiers of this terrible conflict and to 37

“The American people in 1860 believed that they were the happiest and luckiest people in all the world…” little did they realize what was about to unfold B Catton The American Heritage Short History of the Civil War Chap I lns 1-2 American Heritage Publishing Co New York 38 GC Ward 1990 The Civil War: An Illustrated History Alfred Knopf New York 39 On Confederate physician noted “Fellow surgeons condemning compound fractures of the extremities to the knife with as little hesitancy as if men’s limbs,like those of the salamander, were reproduced with great certainty”. HH Cuningham 1958 Doctors in Gray Louisiana State University Press

the time when the American Nation, American Medicine and American Orthopaedic Surgery came of age40.

B

The French and Indian War in the USA(1755-63)

The campaign in which John Hunter came of age. He served with the military for two years at Belle Isle in France and in Portugal. In his subsequent book on gunshot wounds he distinguished between primary and secondary healing, did not advocate debriding wounds nor the removal of bullets and described the contraction of wounds.

B

World War I

The conflict was characterized by the high incidence of gas gangrene from the trenches. At the Inter-Allied Surgical Conference in Paris in 1917 was established the rule for management of war wounds of debridement and delayed closure (unless <8 hours old). Motorized ambulances were introduced, Dakin’s solution used as an antiseptic, and penetrating abdominal injuries explored.

B

World War II

Saw wounds fully debrided and left open, use of whole blood transfusion at the battle front and special surgical units (AUX), use of antibiotics, intramedullary nailing of the femur (established by G Kuntscher,1900-72) and air evacuation. After the war L Bohler (1885-1973) set in writing the standards of fracture management.

40

JE Kuz BP Bengston 1996 Orthopaedic Injuries of the Civil War Kennesaw Mountain Press Georgia

B

Korean conflict

From this arose the MASH unit (near area of conflict), helicopter evacuation over rough terrain, vascular repair in limb injuries, use of antibiotics, and recognition of early renal failure and treatment with haemodialysis.

B

Vietnam War

Further use of helicopter evacuation, laboratory back-up in the field and use of artificial kidney.

It is worthwhile to look at the mortality from injury of these four conflicts to see how trauma services have developed (Table 1.1). From 1972 R L Huckstep (1926-) (Fig 1.4) of Australia established new and innovative standards for complex fracture management (after earlier producing a guide for the care of the patient with poliomyelitis).

Insert Table 1.1 near here

B

Other conflicts and significance

C

Falklands War (1982)

Although developed in earlier wars, the British-Argentinean Conflict saw the widespread use of the the FST, the field surgical team, which was a highly mobile team (surgeon,

anaesthetist, resuscitation officer, four theatre technicians, blood transfusion, technician, clerk), worked independently and operational within 15 minutes.

C

Operation Just Cause, Panama, 1989

Illustrated the need for fast forward units to go with troops into battle. Six emergency room physicians parachuted in with the US assault force to set-up casualty-collecting points from which resuscitated patients were taken to a single joint casualty-collection point for surgery.

C

Operation Desert Storm (1991)

The US-Iraqi Persian Golf War-the most rapid assault and seizure of an objective in modern warfare (100 hours) with a very low loss of troops (331 deaths or 1% of Vietnam fatalities, most noncombatant). This low mortality was due to rapid evacuation and excellent clinical care. Contrast this with the Afghanistan Guerilla War where head, neck, thorax and abdominal injury patients died on the battle field and the nearest hospital was 4 days away(only limb injuries got there for debridement and fixation;10.2% of admissions were for chronic osteomyelitis)41.

B

Organizations and societies

These include: the Committee on Trauma of the American College of Surgeons (ACS)which has advanced the standards of trauma care; American Association for the Surgery of Trauma (AAST-established 1938); the American Trauma Society (founded 1968), the

41

MK Bhatnagar GS Smith 1989 Trauma in the Afghan guerilla war: effects of lack of access to care Surgery 699

American Burn Association founded 1967, the American College of Emergency Physicians and the American Nurse's Association.

A

Future times

Trauma looks likely to remain the unsolved epidemic of developing societies. Specialized care for trauma victims will be the way of the future and the refinement of such care will depend upon innovation, inventions and advances in medical science42. The paper, “Injury in America”43-resulted in the establishment of the Center for Injury Control at the Centers for Disease Control. It seems that, despite the collapse of the USSR, the likelihood of armed conflict will continue from sectarian squabbles and political instability in Developing Countries; many of whom have access to high-technology and nuclear/chemical weapons. The (US) military will be called upon to police upheavals in Europe (Yugoslavia), Middle East (Libya) and Africa (Rwanda). 85% of the support structure for the US Army comes from reserve forces and it will continue to be up to the medical community to support the reserve section of armed force’s medical corps. An important paper in Science has highlighted the challenges ahead44. War and road traffic (motor vehicle) accidents, the 16th and 9th leading causes of DALYs (Disability-Adjusted Life Year; a composite measure of the burden of a health problem) in 1990,will rise to 8th and 3rd respectively by the year 2020. This is thought to be from 42

The World Bank has identified the widening "knowledge gap" between rich and poor nations and is focusing on innovation and research rather than building dams and bridges. Urgent thinking required about development Editorial Nature 1998 395 p527 ie Good science produce inventions which fuels economies. 43 Committee on Trauma Research, National Research Council, and the Institute of Medicine: Injury in America Washington DC National Academy Press 1985.This was a landmark paper; in the same year the US Congress approved a 3 year pilot program to implement its recommendations. 44 CJL Murray AD Lopez 1996 Evidence-Based Health Policy-Lessons from the global Burden of Disease Study Science 274 740-43

the dramatic growth of the young adult population45 as well as the increased use of tobacco and alcohol in the developing World (other risk factors include: malnutrition; poor water supply, sanitation, hygiene; unsafe sex; occupation46, hypertension; physical inactivity; illicit drug use and air pollution). Whilst the challenges of the future seem daunting they are not insurmountable47. Many of our forbears faced and overcame greater problems with significantly fewer resources at hand. Think of what we have48. For instance, Information Technology (simplifying and easing life in the West) has a real chance of solving global poverty by providing lifesaving economic opportunities to countries such as Bangladesh49. Amartya Sen, the 1998 Nobel Prize winner in Economics, has said that societies should attend to the poor and social goals (health and education) otherwise they will be condemning their poor to famine and death (even in the midst of an economic boom) and risk social upheaval (as in Indonesia in 1998)50. Even George Soros has echoed these sentiments and sounded the alarm bells about the relentless and destructive drive of the global free markets in the absence of a global society (health and education should be off-limits to the free

45

China's S-Generation, the single child generation, all 400 million under 20,are triggering a consumer revolution (for S-Type Jags and electronics)with high expectations and a fear of failure. C Li, PA Loconto 1998 China: The Consumer Revolution J Wiley & Sons May be the start of the new S-Age?(ES-comment). 46 In Australia, more people die from workplace accidents than from road traffic accidents. 47 Managed Care-the great “ogre” shifting medical decisions from doctors to accountants and businessmen will falter with time and a new equilibrium established. CE Koop 1998 Protecting Medicine in the 21st century Science 281 p1952-3 48 The Internet may prove bigger than the Industrial Revolution; see www.orthosearch.com; there's alsofractal geometry, quantum teleportation (A Watson 1997 Science 278 p1881-2),and NASA’s “Origins” program to tackle the big questions of life (EJ Chaisson 1997 Science editorial 275 735). 49 The work of this man in creating entrepreneurial opportunities for the rural poor is remarkable and noble. M Yunus Alleviating Poverty Through Technology 1998 SCIENCE 282 p409-10 50 The Real Causes of Famine J Sachs 1998 Viewpoint TIME Oct26,p61.The comment about social upheaval is mine(ES)

marketers)51. And we are at the "dawning of the age of spiritual machines".This may well be the last generation of Homo Sapiens subject to biological wear and demise52. But that may not be enough to get 'Homo sapiens settled down and happy before we wreck the planet'. According to EO Wilson,a distinguished biologist from Harvard, ethics is everything. He has proposed a unity of all knowledge,called Consilience, based not just on expanding scientific frontiers(as one might expect from an American) but long-term contracts,covenants, moral precepts and law,secured by sacred oath53. Hippocrates, Galen, Hunter and our patients would never forgive us if we showed anything but fortitude54, courage and enthusiasm for the opportunities and challenges which face us. Neither would King Conor.

51

G Soros 1998 The Crisis of Global Capitalism: Open Society Endangered. JL Casti 1999 Exit Homo sapiens,stage left Nature 397 p663-4 Homo sapien's day in the sun as the leading intellectual force on the planet is just about over.Computers will have outperformed us within 20 years.Super-intelligent robots "will be our heirs,sharing our goals and values".Such machines will offer "lowly caron-based forms the best chance of immortality". 53 EO Wilson 1998 Consilience The Unity of Knowledge Vintage New York p325-6 Essential reading for all scientists and clinicians. 54 C Gray BMJ 7159 Volume 316: Saturday 5 September 1998 http://classified.bmj.com/careerfocus/ Developing the medical mind….Unlike the gentlemen scholars of past centuries, few doctors today have been trained in thinking or logic, philosophy or ethics, and culture is usually reserved for a sleep in front of Channel 4. ... Most of us get by on pattern recognition, regular routines, and lists of things to do …..doctors of all ages….are failing to make the best use of their brains… 52

Section II - Epidemiology55

A

General principles

Epidemiology (from the Greek epidemion to visit) is the medical discipline that deals with the occurrence, causes and prevention of disease. Its methodology, used in public health to study outbreaks of disease and to design preventive measures, is widely applied in trauma rather than illness or disease. Trauma is the term for bodily damage in a clinical, emergency, surgical or combat setting; injury is used in the non clinical public health literature (but interchangeable with trauma). The epidemiological approach contributes much to better understanding of the incidence and causes of injuries and allows planning of prevention programs and the proper allocation of medical resources. An understanding of the implications of assumptions inherent in the statistical methods underlying epidemiological methods is necessary if some common pitfalls are to be avoided (e.g. no clear hypothesis under test, poor definition of injury type, inappropriate controls, population under study not defined, over-generalization of results).

A

Investigating trauma

Epidemiological approaches to trauma may be descriptive or analytical. Descriptive studies define the problem in terms of incidence and prevalence. Analytical studies seek to identify risk factors with the goal of doing something about the injury rate, or to evaluate the effectiveness of treatment regimes. 55

E Sherry Epidemiology of Sporting Injuries Chap Two in E Sherry SF Wilson Eds 1998 Oxford Handbook of Sports Medicine OUP Oxford

Incidence and prevalence Incidence (rate) of injury is the number of cases per unit time. The rate of injury is measured as the number of injuries or injured athletes (note the significance of the distinction in relation to multiple injuries which may be of different type) over a specified period, and may be expressed in absolute or relative terms. The risk of injury (the probability that an individual will be injured) is measured in the exposed population as a cumulative incidence giving the proportion injured, by actuarial methods (difficult) or from incidence densities. These two parameters provide the basis for most studies of sports injuries. Risk factors Identification of risk factors provides a means for doing something about the sports injury problem. Both the observational and experimental approaches of analytical epidemiology are used56 Observational study designs are of three main types: Case-control (Fig 1.5) - the injured group is compared with a non-injured group in relation to a potential risk factor. Such studies are retrospective, easy to conduct and commonly used, but careful matching of controls is important. The possible sources of bias, role of sampling vagaries and confounding variables must be carefully assessed. Cohort (Fig. 1.6) - similar design, but prospective in that groups exposed or not exposed to a potential risk factor are recognized before injury and then followed through time. This approach is less susceptible to information bias (see below). data collection takes longer and the method is more expensive to implement . Variations include surveillance designs (continuous monitoring of a group of athletes as under the National 56

RL Lieber 1994 Experimental design and statistical analysis. In SR Simon Rd Orthopaedic Basic Science

p 626-659.

Athlete Injury/Illness Reporting System in the USA or NEISS). In survival designs, survival curve analysis is used to follow the reduction in proportion of uninjured/injured over the study period (as in follow-up of orthopaedic joint replacement). Cross-sectional (Fig. 1.7) - documents injuries and risk factors at one point in time, describing prevalence and injury patterns. This approach is of limited value where rehabilitation times after injury are long. Experimental study designs are interventional. Subjects are assigned randomly to treatment or control groups (e.g. prophylactic wearing of ankle splints in basketball). Ethical problems may arise in relation to allocation/withholding of potentially useful treatment. Effectiveness of treatment The effectiveness of treatment is best studied in randomized control trials (Fig. 1.8) which should be double blinded as compliance with protocol is otherwise difficult to achieve. The study plan covers selection of patients (inclusion and exclusion criteria must be clearly defined), random allocation of treatments, treatment and analysis.

A

Steps in study design, implementation and statistical tests

Appropriate study design may at first appear daunting. It is best practice to enlist collaboration with an epidemiologist or statistician before embarking on an investigation to avoid the frustration of having your work rejected on the grounds of unsound design, incorrect statistical analysis or simply failure to prove an hypothesis (hindsight often shows that this would have been possible with proper planning to ensure adequate statistical power, see below). Plan the investigation with definite objectives in view by

formulating test(s) of a working hypothesis (see discussion of null hypotheses below). Know what questions you are asking and why they are relevant in the context of treatment or prevention. Data crunching of large amounts of information 'dredging' for statistically significant relationships of no particular medical significance may be ridiculous and perhaps unethical. Key stages in planning research on sports injuries include: Definition of injury - specification of the particular injury type(s) to be considered will start the investigation. Usually injury is defined as being serious enough to need medical attention from a doctor. Diagnostic tests needed for the study should be assessed for accuracy or predictive value (ability to pick-up the condition). This depends on (1) Sensitivity, measured as the fraction of people with the condition who are actually identified as positives by the test and (2) Specificity, measured as the fraction of people without the condition who are identified as negatives by the test. Predictive value should ideally be near 100% (achieved when both sensitivity and specificity are near 100%). The kappa coefficient estimates interobserver reliability (two or more observers using the same test get the same result). Intraobserver error is a measure of the consistency of one observer over multiple tests. Injury recording requires a numerator (the number of injuries) and denominator (the population at risk, e.g. the number of persons exposed during a specified time period). The population time is the number of participants at risk by the time exposed to potential injury. These units provide a basis for comparisons between studies. Controls must be similar to the study group, using the same inclusion and

exclusion criteria (apart from injury). Bias is systematic error (usually unintentional) resulting in inaccuracy which must be minimized. Such errors may arise from the way that subjects or controls are chosen (selection bias) or measured (information bias), or from confounding variables. Common sources are recall bias (in case-control studies arising from retrospective recall of risk factors); follow-up bias (in cohort studies where players leaving the study differ from those remaining) and historical bias (where 'historical controls' in sequential periods are not aware of other changes). Confounders (confounding variables) are systematic factors associated with the study variable (e.g. risk factor) and the occurrence of injury in such a way as to obscure the true relationship between study variable and injury. The confounder may itself be another risk factor. Features of experimental design may help to mitigate difficulties caused by confounding variables. For instance, in stratified trials, subjects are divided according to one or more of the variables concerned (such as age, gender, smoker/nonsmoker) and subjects in each of these groups are then randomly allocated to control or treatment. The effect of the grouping variable (potential confounder) is thus eliminated. Informed consent of participating patients must be arranged as appropriate in relation to the nature of the investigation before the study can be commenced. This is especially important where treatment alternatives are planned. Where the study may identify particular persons or ethnic/cultural groups, especially in publications dealing with the results, approval of the project by the appropriate community leaders may be required (usually monitored by the research/ethics committees of the researcher's institution. Many journals now require evidence that such approvals were obtained before

considering the results of such studies for publication. Pilot studies (small scale preliminary investigations) are often helpful or even essential. Commencement of a definitive study will typically require approval or award of peer-reviewed competitive funding as well as research/ethics committee approval from the sponsoring institution. Both will ordinarily necessitate assessment of the statistical power (see below) of the proposed investigation. Such calculations require estimation of the expected magnitude and variance of the differences between the groups being compared, and hence the scale of the anticipated response to treatment. Preliminary evaluation of possible confounding factors may also be necessary. A pilot study is often the only way of providing this information where the proposed research breaks new ground. Further, a pilot study may also be helpful in testing and justifying proposed inclusion and exclusion criteria for study subjects, and in providing evidence that proposed recruitment rates are realistic in relation to the proposed time frame of the investigation. Statistical power and the calculation of required sample size Does the observed difference between two groups being compared reflect a real difference between them or is it merely a reflection of chance sampling effects? Statistical tests enable calculation of the probability (P) that a difference as large or larger than observed would arise from random sampling effects alone. If sampling effects would account for differences of the observed magnitude only rarely, we may judge it unlikely that chance alone accounts for the difference and conclude that other systematic factors are involved. But just when do we regard the differences as sufficiently likely to involve factors other than chance sampling effects that we call them 'statistically significant'? Where we set the cut-off

between 'significant' and 'non-significant' is entirely arbitrary. We can set the significance level, denoted as alpha, to any P-value that we consider appropriate for a particular situation. However, by common usage to the point of it having become conventional in biomedical studies, the critical threshold value of P is generally set at 0.05, i.e. alpha = 0.05. At this threshold, if there is 1 chance in 20 or less (<5% probability) that random sampling effects could account for a difference at least as great as that observed, we regard the difference as significant i.e. likely to arise from systematic causes such as the effects of treatment. Other significance levels, such as alpha = 0.02 or 0.01 may of course be chosen according to circumstances, but the criterion to be applied in an investigation should be decided before the analysis is commenced. Formally the use of probability in this way is based on testing the validity of the null hypothesis (Ho) that there is no difference between the populations of which the groups being studied represent random samples in relation to the attributes being compared (mean, variance, proportion, survival curve). For each null hypothesis an alternative hypothesis (H1) exists, here that the populations represented by the study samples are in fact different. In the specific context of risk factor analysis a null hypothesis may be phrased to state that there is no association between the dependent variable (risk factor) and the independent variable (injury). Once the null hypothesis has been formulated and an appropriate statistical test has been selected (Table 1.2), P can be calculated and statistical significance judged according to where alpha was set. Statistical errors of two kinds, known as type I and type II errors, relate to the null hypothesis as follows:

True False

Null hypothesis not rejected Correct Type II error

Null hypothesis rejected Type I error Correct

A type I error arises if the null hypothesis is rejected (because the calculated value of P is less than alpha) even though the null hypothesis is in fact true. A type I error is equivalent to the mistake made if a verdict of guilty is brought in when the accused is innocent. The probability of making a Type I error is alpha which was set by the investigator. the lower alpha is set, the fewer the type I errors, but the higher the chance of type II errors. A type II error arises when the null hypothesis is not rejected even though it is false i.e. the alternative hypothesis (H1) is true. A type II error is equivalent to the mistake made by a verdict of not guilty when the accused is in fact guilty. The probability (beta) of making a type II error depends on the size of the difference specified by the alternative hypothesis (H1), and this reflected a decision on the part of the investigator as to the minimum difference regarded as of practical value or clinical significance. Simultaneously reducing the chances of making type I and II errors means increasing sample size. Whether this is feasible will depend on practical considerations (e.g. recruitment rates) and cost/benefit considerations. Statistical power and the calculation of sample size The power of a statistical test is defined as (1- beta) where beta is the probability of making a type II error (see above). Statistical power is the probability of finding a significant difference when the difference between the populations sampled is delta. The larger the sample size the greater the power of the test. Methods for calculating sample size 57 (appropriate for studies of 57

DG Altman 1991 Practical Statistics for Medical Research. London, Chapman and Hall.;

different kinds are provided in most statistical packages (see below). Remember to include an adequate allowance for likely drop-outs during the study. Long-term studies are particularly susceptible to drop-out losses and poor follow-up rates (few have been successfully completed in the field of sports injuries). Confidence intervals In many circumstances the arbitrary decision significant/not significant may advantageously be replaced or supplemented by specifying confidence intervals (CI, set to any level, but typically 95%) within which population values or differences estimated from the study sample(s) must lie. Outliers Once data is collected, occasional values may be seen to fall outside the range of the main body of data points. These must all be accounted for and must not be arbitrarily discarded as erroneous without investigation. Some will turn out to be due to clerical or instrumental (e.g. calibration shift) errors, unrecognized pathology in the subject, missed exclusion criteria etc. Residual exceptions for which no explanation is found at the time may in future yield new insights. What statistical tests should be used for the analysis? This depends on the objectives of the study and on the kind of data, whether measures of variables with underlying Gaussian (normal) distributions, rank or score data, binomial (two outcome) data or survival curves (Table 1.2). For large scale or complex investigations it is generally prudent to recruit professional statistical collaboration at the planning stage of the project. it may be too late to achieve the full potential of an investigation if this is HA Kahn, CT Sempos 1989 Statistical Methods in Epidemiology. New York, OUP.; WL Hays 1988 Statistics. 4 Ed. Orlando, Harcourt Brace Jovanovich. H Motulsky 1995 Intuitive Biostatistics. New York, OUP.

delayed until after data collection. Implementation of data analysis will typically involve use of a computer software package. Amongst the more widely used professional level packages for independent desk-top use are: Package SYSTAT STATISTICA SPSS/PC+ SAS MINITAB STATGRAPHICS Plus

Company Systat Inc, Evanston, IL, USA StatSoft, Tulsa, OK, USA SPSS Inc, Chicago, IL, USA SAS Institute Inc, Cary, NC, USA Minitab Inc, State College, PA, USA STSC International Ltd., Windsor, Berks, UK

Authoritative but less comprehensive (and less expensive) although adequate for many smaller scale projects are:

Package INSTAT and PRISM STATVIEW

Company GraphPad Software Inc, San Diego, CA, USA Abacus Concepts Inc

What conclusions should be drawn from the study? If the research project was properly planned with clearly formulated objectives based on well-stated hypotheses, the analysis will necessarily provide the basis for statistical (mathematical) findings. But statistical significance does not carry an inference of clinical importance (an observed effect in the real world). Some statistical findings are medically meaningless and sometimes statistics may not detect an important relationship from a given data set (chance, statistical power too low). In summary: •

Shape the investigation by formulation of one or more testable

hypotheses •

Estimate the necessary sample sizes; allow for drop-outs; check that proposed recruitment rates are realistic in relation to the available subject pool

•

Obtain necessary ethics approvals and informed consent of parties and individuals concerned

•

Use eligible subjects; apply inclusion and exclusion criteria rigorously

•

Collect accurate information

•

Watch for, and avoid, bias

•

Eliminate or control confounding variables

•

Practice good management procedures through all phases of the study

•

Evaluate data (examine outliers, check for breakdown of recruitment or blinding criteria)

•

Choose statistical tools appropriate in relation to data type and study objectives

•

Draw conclusions cautiously, with emphasis on medical (rather than mathematical) importance.

A

Meta-analysis

Meta-analysis is a process of systematic review which involves the formulation of a generalized statistical summary of multiple, often independent, research results relating to a given topic58. The goal in the medical context is to combine heterogeneous pooled data so as to minimize the effects of experimental variation (technical, genetic, and

Chambers I and Altman DG 1995. Systematic Reviews. BMJ Publishing, London. Cook TD et al. 1992. Meta-analysis for explanation: a Casebook. Sage, New York. 58

environmental), sampling bias and random error amongst the several studies as a basis for assessing the effectiveness of treatment or management approaches to a health problem59. It offers no universal solution in the search for optimal medical treatments and ‘best practice’ and must always be subject to critical evaluation. The value of the output must clearly depend on the generalizability, scale and sampling strategies of the input studies 60. The role of meta-analysis is perhaps especially evident in surgery, where limited facilities, cost, achievable recruitment rates and ethical considerations often limit studies to a very small scale statistically (in contrast for instance to very large scale international drug trials). If the best that can be achieved in relation to a given intervention is reflected in reports of heterogeneous ‘little experiments’ in the literature, meta-analysis provides an approach to extracting generalizations across variation in, for instance, experimental validity and the age, sex, genetic/ethnic background, nutritional status, physiology and behaviour (drug use, exercise) of the subjects. But just as the power and potentially unique contribution of meta-analysis comes from combining the results of multiple small studies on a particular topic, so its greatest potential weakness is that any incorrect conclusion reached may superficially appear scientifically robust due to the false security provided by a base of multiple samples and apparent replication. LeLorier et al. (1997)61 suggest that conclusions from meta-analyses of drug trials may have supported

Cook TD et al. 1992. Meta-analysis for explanation: a Casebook. Sage, New York. Hedges LV and Olkin I 1985. Statistical Methods for Meta-analysis. Academic Press, Orlando. Hunter JE and Schmidt FL 1990. Methods of Meta-analysis. Sage, New York. 60 Dickersin K Scherer R and Lefebvre C 1994. Identifying relevant studies for systematic reviews. BMJ 309:1286-1291. 61 LeLorier J et al. 1997 Discrepancies between meta-analyses and subsequent large randomized, controlled trials. New England J Med 337:536-542. 59

ineffective treatment regimes in as many as about 30% of instances while also leading to rejection of useful treatments in about 30% of instances. With these limitations in view, special attention needs to be given to defining the criteria by which studies are selected for inclusion in a meta-analysis 62.A systematic approach to grouping of studies for meta-analysis is encouraged by use of dedicated special-purpose computer programs such as MetaWin 63. Meta-analysis typically involves dealing with standardized mean differences, proportions and correlations using fixed- and random-effects models as well as generation of probability-value summaries. Outlier studies should be identified in preliminary analysis and may need to be eliminated. Examination of the combined data using randomization tests may be useful. Covariation of characters in real data sets is expected to be much higher than in comparable randomly generated, simulated data sets Thus, the strength of apparent associations can be examined by comparison over a specified number of iterations with the patterns of covariation among characters seen in randomly generated permutations of the data. Measures of the robustness of conclusions generated in meta-analysis may be generated using parametric or non-parametric resampling techniques. These approaches attempt to measure an unknown distribution by repeated resampling from the data (taken to represent the sample distribution). Bootstrapping involves repeated construction of simulated data sets by random sampling of specified elements of the actual data matrix. Estimates of the frequency of occurrence of particular features in more than, say, 100 repeats of this procedure can be used as indices of the level of support for that feature, 62

Chambers I and Altman DG 1995. Systematic Reviews. BMJ Publishing, London Rosenberg MS Adams DC and Gurevich J 1997. MetaWin. (A computer program for meta-analysis written for Microsoft Windows 3.1, 95, NT). Sinauer Associates, Sunderland. 63

akin to setting confidence limits. Jack-knifing involves repeated resampling from a simulated data set from which selected elements are systematically omitted without replacement, to generate a measure of support for the existence of a particular feature.

A

Overview of trauma epidemiology in the USA

JT Murphy has provided a succinct overview of trauma epidemiology in the USA64: •trauma is the leading health problem in the USA with >140,000 deaths annually (147,891in 1995) and the leading cause of years of potential life lost prior to age 65 (before cancer and heart disease).65 See Table 1.3 •most injuries are probably preventable •one third of the population sustain a non-fatal injury each year(most common cause of death<34 years).There were 59,127,000 injuries reported in 1995. •trauma is the leading cause of lost work hours •one out of every eight beds in the USA is for trauma •80,000 people sustain severe brain/spinal cord injuries annually •the cost in 1988 was US$180 billion •men are 2.5 greater risk>women •the death rate is highest in poor urban areas •>one half of motor vehicle accidents (MVAs) are alcohol-related 64

JT Murphy Chap One Epidemiology of Trauma 1994 The Parkland Handbook Trauma Handbook M A Lopez-Viego Ed Mosby-Year Book, St Louis, Missouri . Much of this data is from the National Centre for Health Statistics in the USA which publishes a yearly mortality report which summarizes deaths in the USA. 65 NCHS Vital Statistics System 1995 www.cdc.gov/ncip

•>90% survive their injury •-60% deaths occur in first 24 hours •most highly injured group are 15-24 years with MVA causing >54 % injuries •-falls exceed MVAs as the leading cause of nonfatal injuries (and cause 12,000 deaths/year; elderly are at greatest risk). •rate of homicide death is 12.7/100,000 in USA (versus 2.7 in Australia,2.4 Italy,1.0 Japan and 0.8 in UK) •75% homicides were firearm related, handguns (homicide is the leading cause of death for black males aged 15-24 years; and leading cause of occupational death in New York City and Los Angeles)66. "If current trends continue, by the year 2003 firearm deaths will surpass motor vehicle-related deaths as the leading cause of injury and death in the US"67. •burns cause 6,000 deaths/year (death is from inhalation of CO and toxic substances, alcohol and cigarettes are factors in house fires), lightning causes 80 deaths/year. However decreasing incidence with education about smoking and alcohol use in bed along with the use of fire-proof clothing and bedclothes. •there were 30,484 suicide deaths in 1992(80% white males)

It is important to know the trimodal distribution of deaths from trauma in regard to time. There are 3 peaks (immediate, half of all deaths, not possible to save, from massive head injury/brain stem injury/major cardiovascular; early, within first few hours, 66

ML Rosenberg et al have identified biological (eg. age, gender, psychiatric illness)and sociological factors(based on social learning theory where culprits learn from their violent peers with cultural, structural(poverty), interactionist and economic features) to account for assaultive violence in the USA. 1991 Violence in America :A Public Health Approach OUP New York 67 MD Grossman 1998 Introduction to trauma Care Chap One in Trauma Manual Eds AB Peitzman et al Lippincott-Raven Philadelphia

from torso trauma in these cases, introduces concept of "golden hour"; late deaths, about 20% of all, from organ failure and sepsis, influenced by inadequate early resuscitation or care)68.

A

Trauma in UK, Australia, Europe, Singapore and Developing World

B

Trauma in the United Kingdom69

Within the UK the supervision of care of Accident & Emergency Department was the responsible of Orthopaedic surgeons until in 1970 the Accident Services review committee indicated that from the staffing point of view, the Orthopaedic solution had failed(consultant cover in Accident & Emergency Department was nominal only).From 1971 the Joint Consultants Committee recommended that Accident & Emergency Departments be placed under the control of a Consultant in Accident & Emergency Medicine with registrar training programs. Less than 10% of UK Orthopaedic Consultants give musculoskeletal trauma as their major interest (only about a dozen surgeons out of >1,000 practice primary and secondary trauma alone). In the United Kingdom with a population of 55 million there are about 900,000 musculoskeletal injuries each year, of which >100,000 are left with a significant disability. Only two units, Edinburgh and Oxford, have completely separated the management of acute injuries from elective practice. In Oxford the unit is staffed twenty-four hours per day by a resident consultant traumatologist. In Edinburgh the unit is staffed by a non-resident consultant.

68 69

DD Trunkey 1983 The trimodal distribution of death after injury. Scientific American 249 2 C Oliver 1997 Trauma Column WorldOrtho www.worldortho.com

The Oxford consultants act as trauma team leaders in Accident and Emergency whilst the Edinburgh consultants triage through the Accident and Emergency Consultants.

B

Trauma in Australia

Similar data to the USA exists in Australia for general injury and motor vehicle fatalities (Table 1.4) with significantly fewer firearm injuries and declining road fatalities, especially since 198970, (Table 1.5) because of random alcohol breath testing and use of seat belts and airbags. There are significant numbers of swimming pool fatalities involving children.

B

Trauma in Europe

Insert Table 1.6 here

B

Trauma in Singapore

Trauma is the leading cause of death in Singapore for those<40 years71. Over half are from motor vehicle accidents, <3.5% from assault and no gunshot injuries (stiff legal penalties have almost abolished private ownership of firearms in this country). Although 77.6% are unavoidable, 25% have been found to be potentially or frankly preventable72.

70

Federal Office of Road Safety,Australia http://www.dot.gov.au/ for further information, email: [email protected]. 71

PTC Iau et al 1998 Preventable Trauma Deaths in Singapore 1998 Aust NZ J Surg 68 820-25 Guidelines of the Trauma Research &Educational Foundation of San Diego, classified as "not preventable", "potentially preventable" and "frankly preventable". 72

Even in a small island city-state 50km long with 5 government general hospitals the "scoop-and-scoot" policy before stabilization (airway management, stabilize fractures and fluid resuscitation) should be abandoned.

B

Trauma in the Developing World

There is a growing epidemic of trauma in the Developing World which has been noted by orthopaedic surgeons working in these areas. In particular, motor vehicle accidents which are now the third highest cause of death.73 Factors include: the large number of pedestrians and cyclists (many living below the poverty line) involved in RTAs; overcrowding of public transport; poor maintenance of roads; few speed restrictions; and the under-developed medical management and treatment of such trauma. This does not include the non-fatal trauma which occurs at home (poor vision from cataracts may be a significant factor) and in the workplace and also from natural disasters. Pearn, Taylor and Holian have written about the Aitape tsunami disaster which hit Papua New Guinea, July 1998,when waves, up to 15 metres, travelling at 100km/hr, struck a 33km coast line and destroyed 16 villages, 2200 died and displaced 9,000 people74. Otherwise little data exists in this area.

73

WJ Cumming 1998 Newsletter WOC 76 p1-3. Rescue Pearn et al.1998 Med J Aust 169,11/12 p601-10 Pearn emphasized the skills of triage, the need for speed and prevention of secondary trauma and disease. Aims of treatment were diagnosis, debridement, effective traction and immobilization of fractures with definitive fixation in the second week. The Red Cross surgical principles(wound assessment, wound excision and decompression, antibiotics, IV chloramphenicol, undisturbed dressing techniques, odour/temperature and pulse as indicators of inadequate initial wound care, delayed primary closure with/out skin grafting at 4 to 5 days)were followed. 74

A

Prevention

W Haddon, the first Director of the US National Highway Traffic Safety Administration, formulated a conceptual approach to injury prevention (essentially host/vehicle/environment)75: -prevent the creation of hazards (limit firearm sales e.g. Handgun control in Australia in 1997) -reduce the number of hazards -preventing the release of a hazard (child-proof medication holders) or modify its release -separate hazards from hosts in terms of space and time (traffic overpasses to prevent congestion) -use material barriers (screens) -modify basic qualities of hazards (air-bags) -make hosts more resistant to damage -counter damage already present (first aid training) -stabilize, repair and rehabilitate the injured This is covered by 3 basic strategies-Education and Persuasion (public education campaigns with intention of altering behaviour; such as driver education about fatigue and alcohol/drug, use of seat belts and air bags, not often successful where compliance required e.g. putting on seat belt versus automatic triggering of airbags); Legal regulation of Behaviour (to protect individual and others exposed such as speed

75

W Haddon 1972 A logical framework for categorizing highway safety phenomena and activity J. Trauma 12 297

restrictions, which decreases injury rate76 , use of helmets and alcohol restriction) and Automatic Protection (car manufacture standards to include-glare reduction/braking systems/seatbelts/head restraints/collapsing steering columns/puncture-resistant gas tanks /child restraints; building better and safer highways with divided highways/break away light poles; water sprinklers in buildings). All such measures need to be subjected to costbenefit analysis (how much to spend, how to spend it and how to make the service available). Haddon’s approach has been hailed as the greatest public health achievements of the century which has reduced the US road mortality to one third of that of the 1950. In contrast little progress has been made in reducing firearm violence in the US. Such measures can be reduced to four steps: (1) Define the problem, (2) Identify causes and risk factors, (3) Develop and test interventions, (4) Implement interventions and evaluate their impact.

76

Kloeden CN, McLean AJ, Moore VM Ponte G 1998. Travelling speed and the risk of crash involvement. FORS CR 172http://raru.adelaide.edu.au/speed/