Biomedical subjects
Publications and source records attributed to R R Simon.
Metacarpal and phalangeal fractures are common presenting injuries in many emergency departments. The emergency physician should become skilled at properly evaluating and initiating appropriate management and follow-up for these injuries when they occur. Failure to properly do so may result in permanent disability.
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Immediate control of the airway in a patient with massive neck swelling caused by cervical or maxillofacial trauma is often difficult. A modified new technique, discussed in this article, has been developed based on anatomic principles for the performance of a modified tracheotomy in these patients.
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We first developed a technique for cutdown of the cephalic vein at the wrist. We then conducted a prospective cross-over cadaver study comparing the ability of medical students to perform this technique with that of the standard saphenous vein cutdown at the ankle. All students had a previous course in anatomy but had never performed a cutdown. Before testing, the students were given written material and a ten-minute lecture describing both approaches. Seventeen students performed 34 cutdowns; nine students attempted the cephalic cutdown followed by the saphenous cutdown; the remaining eight used the reverse order. The mean time (+/- SD) to isolation of the cephalic vein was 85 +/- 70 seconds; for the saphenous vein, mean time was 70 +/- 89 seconds (P = NS). There was one failure (inability to isolate the vein within five minutes) in 17 attempts at the cephalic vein and two failures in 17 attempts at the saphenous (P = NS). There were no complications (nerve, artery, or tendon injury) with either technique. The mean external vein diameter (+/- SD) of the cephalic vein and the saphenous vein were 3.2 +/- 1.0 mm and 3.6 +/- 0.7 mm, respectively (P = NS). We conclude that relatively inexperienced providers can learn to perform the cephalic vein cutdown at the wrist on fresh cadavers with similar speed and success as that for the saphenous vein cutdown at the ankle. Cutdown at this site may provide a useful alternative to the saphenous cutdown in certain clinical situations.
The logistics of maintaining and supplying underground clinics located in war-torn rural Afghanistan are presented. Medical supplies are transported by pack animals over mountainous terrain, and must be specially packaged for the rigorous journey. Twenty percent of supplies are lost en route due to attacks or accidents. Medical and surgical equipment, some of which had to be specially designed, must be lightweight and durable. The system of monitoring clinic efficacy is also discussed.
We discuss the establishment of underground surgical theatres in resistance-held, rural Afghanistan by the IMC. The limitations of working in facilities without electricity or modern surgical equipment or even adequate suction are discussed, and the methods we have implemented to deal with these limitations are presented.
A surgical training model developed and implemented by the IMC for the training of advanced surgically capable medics operating in resistance-held rural Afghanistan is presented. Existing training programs for medics and midlevel health care workers are discussed, but these offer little or no surgical training and depend on a tiered system of referrals that is not possible in resistance-held Afghanistan. Details of the medics' training, enabling them to diagnose and treat 75% of war-related injuries in the rural population, are presented, as is the rationale for development of the model, based on data from other conflicts.
Sterilization equipment and techniques available to forward surgical units in modern conflicts past and present are sophisticated and generally taken for granted. Underground surgical units operating in rural Afghanistan must function without electricity or petroleum-powered generators and, with few exceptions, are unable to use sterilization equipment that produces intense heat for prolonged periods. We discuss the equipment and techniques developed for use by the IMC to sterilize surgical instruments, gowns, gloves, rubber goods, and sutures in the 42 clinics operating in resistance-held Afghanistan. These techniques may have application to other similar primitive conditions.
This study compares a moisture-vapour-permeable film (MVPF) with silver sulphadiazine in a randomized prospective manner for the treatment of outpatient burns. The two treatment groups were closely matched in age, sex, per cent of BSA burned, and in burn severity and locations. The MVPF group demonstrated a 39.0 per cent greater reduction in pain after application of the dressing over the silver sulphadiazine group. Patients in the MVPF film group also reported significantly less difficulty in wound care and in dressing interference with their daily functions. The clinical infection rate and time to healing were similar in both groups. In the management of outpatient burns, MVPF was found to be superior to silver sulphadiazine.
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Subungual hematomas are one of the most common injuries involving the hand. On conducting a literature search, we were unable to find any studies that investigated the association between subungual hematomas, fractures, and the presence of an occult laceration of the nail bed requiring repair. Forty-seven consecutive patients who presented to the emergency department with subungual hematoma involving more than one fourth of the nail bed were included in this study. In these cases, radiographs were taken, and the nail was lifted to look for a laceration. In the subgroup of patients who had subungual hematoma associated with a fracture, all of them had a laceration requiring repair. Patients with a subungual hematoma greater than one half of the size of the nail bed had a 60% incidence of a laceration requiring repair. The authors believe that patients presenting with a subungual hematoma involving greater than one half of the nail surface and a fracture of the distal phalanx should have the nail lifted and the nail bed explored and repaired.
We studied the venous system at the groin, ankle, and antecubital area in relationship to easily palpable or visible surface landmarks, and developed new approaches or modifications of existing approaches to localize the saphenous vein at the groin, ankle, and the basilic vein in the antecubital area. A prospective crossover study comparing these new cutdown techniques with the most commonly described traditional techniques was performed, using inexperienced medical personnel. They were divided into two groups, and the average time to successful venous isolation with each method at each of the three sites was studied. Both groups were similar in that all participants were medical personnel (interns, flight nurses, an equal number in each group) who had not previously performed venous cutdowns. In each group, at all sites, the new cutdown techniques resulted in a more rapid isolation of the vein. This was true in each case regardless of which technique was learned and attempted first.
The role of intravenous pyelography (IVP) in the evaluation of blunt abdominal trauma is controversial. Major renal injuries have occasionally been reported in the absence of hematuria, but the test is not always accurate, is expensive and has potential morbidity. By reviewing the charts of 150 consecutive patients seen in an emergency department who had IVP for blunt abdominal trauma, we evaluated the ability of clinical and laboratory findings to predict IVP findings, the incidence of abnormal findings on IVP and the number of times IVP affected patient management. Only one patient's management was found to be clearly affected by the results of the IVP. We feel, therefore, that IVP should be reserved in cases of blunt abdominal trauma for patients with gross hematuria and those with microscopic hematuria and suggestive clinical findings. The absence of hematuria should preclude the use of IVP unless there are other exceedingly strong clinical findings.
A literature search failed to demonstrate any investigations of the plain films of the ankle to determine whether there were any measurable differences in the ankle mortise, which would differentiate between a second and a third degree ankle sprain, thus obviating the need for stress views. In this study, the authors independently measured the distances between the talus and tibia at eight predetermined sites on the lateral and mortise views. This was done blindly so that neither author knew which cases were second- or third-degree ankle sprains. Only definite third-degree ankle sprains, as defined by a positive anterior drawer sign and/or a positive inversion stress test result on clinical evaluation, were included. The authors found there was severe interobserver variability. The authors thus feel that there is no clinically significant measurement on plain films of the ankle that can be used to differentiate accurately between second and third degree ankle sprains, and current reliance on clinical findings and subsequent stress x-ray films is appropriate and must remain the non-operative standard for evaluation of this problem.
We have focused on those features of emergency medicine that distinguish it as a separate and independent specialty. We have emphasized rapidity and efficiency in approach to emergency patients with chief complaint, set of vital signs, and general appearance, mandating an appropriate history, physical examination, and generic differential diagnosis. The most serious illness (not the most probable) is considered first and the patient protected against the morbid complications of the most serious disease(s). We have pointed out that the development of a rapid rapport with patients, prioritization of care between patients and even between organ systems in a single patient, and a breadth and depth of expertise and technical skills in dealing with the initial presentation of a variety of common acute illnesses are intrinsic to emergency medicine. It is true that emergency physicians and other physicians overlap at times with regard to each of these characteristics. However, as a whole, these facets define a constellation of special expertise. The key to the specialty of emergency medicine is the ability to successfully manage the acute deterioration and pathophysiology of any life or limb threat. There are many technical skills pertinent to this management which are often shared with other disciplines, but the judgment required to manage this acute deterioration, in fact, defines the specialty of emergency medicine.
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