[Air ambulance intensive care transport in prone position for COVID-19 ARDS]. / Luftgebundene Intensivverlegung in Bauchlage bei COVID-19-ARDS.

An EMS helicopter was scheduled to transport a woman with COVID-19 acute respiratory distress syndrome. However, the patient was found in prone position in the delivering hospital. After repositioning in the supine position, life-threatening hypoxemia occurred, so that the patient had to be returned to the prone position. After a structured decision making process, the patient could be transported with the helicopter without complications in prone position. Fortunately, the patient was stabilized in the further course of the disease and was transferred to a weaning facility breathing spontaneously with pressure support.

[Conventional intubation and laryngeal tube in cervical spine instability : Changes in the width of the dural sac in unfixed human body donors]. / Konventionelle Intubation und Larynxtubus bei Halswirbelsäuleninstabilität : Änderungen der Duralsackweite am unfixierten humanen Körperspender.

BACKGROUND: Airway management in patients with an unstable cervical spine requires a cautious approach if secondary damage is to be prevented but the question regarding the optimum method remains unresolved. The primary aim of the study was to investigate whether there were differences between intubation by conventional Macintosh laryngoscopy and placement of a laryngeal tube (LTS-D) with respect to dural sac compression on an unfixed human cadaver model with unstable injuries of the upper cervical spine. Secondary parameters that could be relevant in patients with unstable spinal injuries were also investigated. MATERIAL AND METHODS: Orotracheal intubation by conventional direct laryngoscopy using a Macintosh blade and placement of a laryngeal tube (LTS-D) were performed in six fresh human cadavers. The dural sac was filled with contrast dye to allow continuous myelography by lateral fluoroscopy. Changes in the width of the dural sac at the cervical segments (C) C0/C1 and the C1/C2 levels as well as secondary parameters (angulation, distraction, intervention time) were assessed in the intact spine as well as in the presence of combined atlanto-occipital dislocation and atlanto-axial instability. The intubation methods were considered independent and examined using the Mann-Whitney U­test. RESULTS: At the C0/C1 level in the intact spine, conventional laryngoscopy caused less reduction of the width of the dural sac than placement of the LTS-D (0.33 mm vs. 0.46 mm, p = 0.035); however, in the presence of combined atlanto-occipital dislocation and atlanto-axial instability, placement of the LTS-D caused less reduction in the width of the dural sac than conventional intubation (1.18 mm vs. 0.68 mm, p = 0.005). At the C1/C2 level no differences were found with respect to changes in the width of the dural sac, neither in the intact spine nor in combined atlanto-occipital dislocation and atlanto-axial instability. Conventional intubation caused more angulation than placement of the LTS-D at both levels measured. Both methods did not cause distraction. The intervention times for placement of the laryngeal tube were shorter. CONCLUSION: In an unfixed human cadaver model with combined atlanto-occipital dislocation and atlanto-axial instability, placement of the LTS-D caused less reduction in the width of the dural sac than conventional intubation at the level of the craniocervical junction. The LTS-D also caused less angulation and could be placed faster. It could therefore also be advantageous over conventional intubation in living patients with an unstable cervical spine.

[Parameters influencing the preclinical application of cervical collars]. / Einflussfaktoren auf die präklinische Anlage einer Zervikalstütze.

BACKGROUND: The application of cervical collars is a standard procedure in emergency care of trauma patients. It is often observed that the application of cervical collars is performed incorrectly, which may lead to reduced immobilization of the cervical spine. OBJECTIVES: The objective of this study was to analyze the practical skills of professional emergency care providers concerning the application of cervical collars. MATERIALS AND METHODS: Emergency care professionals (n = 104) were asked to apply a cervical collar to a training doll. Each performance step was assessed separately. Furthermore, personal and occupational data of all study participants were collected using a questionnaire. RESULTS: The study participants included professional rescue personnel and emergency physicians. The average occupational experience of all study participants in out-of-hospital emergency care was 11.1 ± 8.9 years. Most participants had already received training on trauma care (61 %) and felt "very confident" in handling a cervical collar (84 %). The application of the cervical collar was performed correctly in 11 % of the performances. The most common error was incorrect size adjustment of the cervical collar (66 %). No association was found between the correct application of the cervical collar and possible parameters of influence, such as working experience in emergency care or participation in trauma courses. CONCLUSIONS: Despite pronounced subjective confidence regarding the application of cervical collars, this study shows that there are general deficits in the practical skills of applying cervical collars. Therefore, a critical assessment of the current training contents on the subject of trauma care must be demanded.

[Interpersonal competence in orthopedics and traumatology : Why technical and procedural skills alone are not sufficient]. / Interpersonelle Kompetenz in Orthopädie und Unfallchirurgie : Warum technische und prozedurale Fähigkeiten alleine nicht ausreichen.

Patient safety has increasingly gained significance as criterion which clinics and doctors will be measured against in terms of ethics and finances. The "human factor" moved into focus regarding the question of how to reduce treatment errors in clinical daily routine. Nevertheless, systematic mediation of interpersonal competences only plays a minor role in the catalogue of requirements for medical specialization and professional training. This is the case not only in orthopedics and traumatology, but in other medical fields as well. At the insistence of DGOU and in cooperation with Lufthansa Flight Training, a training model was initiated, comparable to training models used in aviation. In aviation, apart from the training of procedural and technical abilities, regular soft skills training has become standard in the training of all Lufthansa staff. Several studies confirm that by improving communication, interaction, and teamwork skills not only a reduction of intolerable incidents is observed, but also a positive economic effect. Interpersonal competences should be firmly anchored in orthopedics and traumatology and thus be implemented as third post in specialist training.

[Standardisation of the Initial Treatment of Severely Burned Patients: The Necessary Transfer of Concepts from Trauma Care]. / Standardisierung der Initialbehandlung von Schwerbrandverletzten: Die notwendige Übertragung von Konzepten aus der Schwerverletztenversorgung.

The initial treatment of severely burned patients remains a huge challenge for first responders in emergency services as well as emergency doctors who do not work in a centre for severe burn injuries. The reason for this is the low number of cases in developed countries and a lack of training concepts for the specific aspects of the initial treatment of severe burn injuries. Because of guidelines with limited evidence (S1, S2k) and a lack of structured treatment approaches, uncertainties with respect to initial treatment are still visible. Even within the professional societies and on international comparison, controversial aspects remain. In contrast, optimised and standardised procedures are available for the treatment of severely injured (trauma) patients, based on PHTLS® (Pre Hospital Trauma Life Support) for preclinical and ATLS® (Advanced Trauma Life Support) for in-hospital first aid. This article takes stock of the current structure of care and the relevant evidence for the initial treatment of severe burns. Also it discusses a possible transfer and further development of concepts for primary trauma care by all disciplines involved. Nine essential steps in the primary care of burned patients are identified and evaluated. The need for the introduction of a uniform treatment algorithm is illustrated. The treatment algorithm presented in this article addresses all first responders who are faced with initial treatment in the first 24 hours outside of burn centres. As an essential, new aspect, it offers a transfer and adaptation of concepts from trauma care to standardise the care of severely burned patients.

[Further training in the faculty of orthopedics and trauma surgery. Outstanding, average or insufficient?]. / Weiterbildung im Fach Orthopädie und Unfallchirurgie. Mustergültig, mittelmäßig oder mangelhaft?

A well structured and executed and practical residency program is important to secure a sufficient number of well trained orthopedic surgeons in the future. Some of the residents, however, see substantial shortcomings here. Additionally, orthopedic residency programs struggle to be a valid alternative for graduated medical students when comparing them to residency programs in other medical specialities or alternative job options. In improving the current situation program directors as well as residents must play a key role. A rapid improvement of structural shortcomings of German residency programs does not only provide an advantage in recruiting new residents now, but may also help to maintain the high quality in orthopedic health care in the future.

[Compatibility of science and clinical aspects. Between realism and utopia]. / Vereinbarkeit von Wissenschaft und Klinik. Zwischen Realismus und Utopie.

The working environment for young residents in orthopedic surgery has changed tremendously over the past 10 years. Due to cumulative clinical requirements and increasing demands on work-life balance research activity has become less attractive. Successful incorporation of research into the career of residents is a challenging project for the future. The young forum of the German Association for Orthopedics and Traumatology (DGOU) provides different approaches to enhance the quality of research and to help young orthopedists and trauma surgeons.

[How many generalists and how many specialists does orthopedics and traumatology need?]. / Wie viel Generalist und wie viel Spezialist braucht die Orthopädie und Unfallchirurgie?

The training in orthopedic and trauma surgery has changed significantly with the introduction of the new residency program. The contents taught have already been reduced in breadth and the current developments in the outpatient and particularly in the clinical landscape also contribute to increasing specialization. This trend favors structures in which comprehensive medical care for the population in Germany in orthopedic and trauma surgery appears to be endangered and in which the future efforts for e.g. polytraumatised patients need to be questioned. The Young Forum of the German Society for Orthopedics and Traumatology actively accompanies a discussion about the necessity and value of generalists to ensure the level of care in Germany in addition to the specialists.

[Six years of Advanced Trauma Life Support (ATLS) in Germany: the 100th provider course in Hamburg]. / Sechs Jahre Advanced Trauma Life Support (ATLS) in Deutschland: 100. Providerkurs in Hamburg.

With over 1 million certified physicians in more than 50 countries worldwide, the Advanced Trauma Life Support (ATLS) concept is one of the most successful international education programs. The concept is simple, priority-orientated (ABCDE scheme) and assesses the situation of the trauma patient on the basis of vital signs to treat the life-threatening injuries immediately. With over 100 ATLS provider courses and 10 instruction courses accomplished in less than 6 years, no other land in the world has successfully established this concept in such a short time as Germany. Meanwhile nearly 1,600 colleagues have been trained and certified. Evaluation of the first 100 ATLS courses in Germany supports this concept. The total evaluation of all courses is 1.36 (1.06-1.8, n=100). The individual parts of the course were marked as followed: presentations 1.6 (1.0-2.81, n=100), practical skills stations 1.46 (1.0-2.4, n=100) and surgical skills stations 1.38 (1.0-2.38, n=100). In 2009 a total of 47 ATLS courses were accomplished which will clearly increase in 2010. Other ATLS formats, such as ATCN (Advanced Trauma Care for Nurses) and refresher courses are planned for the beginning of 2010.

[Polytrauma in old age-Knowledge from the TraumaRegister DGU®]. / Polytrauma im Alter ­ Erkenntnisse aus dem TraumaRegister DGU®.

The geriatric fracture patient is becoming more and more in the forefront due to the demographic development. It is expected that the number of polytraumatized geriatric patients in the coming years will rise in line with demographic trends. The TraumaRegister DGU® of the German Trauma Society (DGU) provides interesting insights into the age structure and patient outcome. In 2017 in total 26.2% of the patients included were over 70 years old. Geriatric polytraumatized patients show significant differences in the injury patterns as well as in the treatment strategy compared to younger patients. This is often due to the pre-existing diseases and various drugs that alter the physiology. With respect to the injury patterns an increase in severe head injuries and a decrease in severe abdominal injuries can be seen with increasing age. Hospitals and professional societies are currently dealing with numerous challenges. The implementation of the General Data Protection Regulation leads to conflicts and uncertainties. The further development of the TraumaRegister DGU® is important in order to collect more outcome-relevant data from patients because more than ever the objective should be the survival of an accident with a high quality of life. To measure this, a structured survey of patients is necessary. The TraumaRegister DGU® is one of the most important tools to make treatment comparable and to measure structural changes.

Expertise of German paramedics concerning the prehospital treatment of patients with spinal trauma.

PURPOSE: Spinal immobilization is a standard procedure in emergency medicine. Increasing awareness of complications associated with immobilization of trauma patients leads to controversial discussions in the literature. Current guidelines require to include considerations of accident mechanism, an assessment of the patient's condition and an examination of the spine in the decision-making process if immobilization of the spine should be performed. This requires sound knowledge of assessing these parameters. The aim of the current study is to analyze German paramedics' subjective uncertainty in terms of their prehospital assessment and treatment of patients suffering from spine injuries. METHODS: Over a period of 17 months participants in a trauma course were asked to complete a standardized anonymous questionnaire about subjective uncertainty of prehospital assessment and management of spinal trauma before participation in that course. Questions about the frequency of application of different immobilization tools and skills training on spinal immobilization were also asked. RESULTS: A total of 465 paramedics were surveyed. The participants did not indicate any uncertainty about the prehospital diagnosis and treatment of spinal injuries. The feeling of confidence was significantly greater in participants who had already attended another course on structured trauma care before. The participants agreed with the statements that standardized algorithms facilitate teamwork and that there is a need for a protocol for the prehospital treatment of spinal injuries. CONCLUSIONS: Paramedics do not feel uncertain about the prehospital assessment and treatment of spinal injuries. The feeling of confidence in participants who had already attended a course on the treatment of trauma patients before was significantly higher.

[Safety culture in orthopedics and trauma surgery : Course concept: interpersonal competence by the German Society for Orthopaedics and Trauma (DGOU) and Lufthansa Aviation Training]. / Sicherheitskultur in Orthopädie und Unfallchirurgie : Kurskonzept: Interpersonal Competence by Deutsche Gesellschaft für Orthopädie und Unfallchirurgie (DGOU) and Lufthansa Aviation Training.

Patient safety has become a central and measurable key factor in the routine daily medical practice. The human factor plays a decisive role in safety culture and has moved into focus regarding the reduction of treatment errors and undesired critical incidents. Nonetheless, the systematic training in communication and interpersonal competences has so far only played a minor role. The German Society of Orthopaedics and Trauma (DGOU) in cooperation with the Lufthansa Aviation Training initiated a course system for interpersonal competence. Several studies confirmed the reduction of critical incidents and costs after implementation of a regular and targeted human factor training. The interpersonal competence should be an essential component of specialist training within the framework of a 3­column model.

[The Summer School of the German Society for Orthopaedics and Traumatology - A Success Story]. / Die Summer School der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie ­ eine Erfolgsgeschichte.

Background: It has been known for several years that orthopaedic and trauma clinics suffer from a shortage of young people, due to the substantial loss in attractiveness. The Youth Forum OU has been addressing this problem for many years, by initiating many projects such as the Summer School to counteract this trend. The purpose of this research is to evaluate the success of Summer Schools since 2009. Methods: The Youth Forum OU performed a survey in December 2014 to answer the research question on the basis of an internet-based poll of the student participants in all Summer Schools between 2009 and 2014. Following data cleansing, 121 students and former students were included in the survey. Results: Seventy-two completed questionnaires were collected and included in the evaluation. The survey included 40 % of Summer School participants, with a mean age of 27.3 years (SD ± 2.95); 50 % were female. Participation in the Summer School helped 50 % of the respondents to decide to start advanced study in orthopaedics and/or traumatology (OU). One third of these Summer School participants had already finished a university degree; 100 % are now residents in orthopaedics and/or traumatology. Regardless of prior plans, 87.2 % of participants are now residents in OU. Thirty-three are still students: 78.8 % have already decided to work in OU. The survey also served to identify the factors positively and negatively associated with OU. Unfavourable factors included the reputation of OU, and the difficulty of reconciling family and work. Favourable factors included surgical work and personal experience during university studies. Discussion: The aim of this study was to evaluate whether the efforts of the Youth Forum OU, the German Society for Orthopaedics and Traumatology (DGOU) and the local hospitals lead to increased interest in OU. The answer to this question is positive. This is particularly true for those students who did not plan to become an orthopaedic or trauma surgeon before participating in a Summer School. In conclusion, the efforts to recruit residents for OU by using Summer Schools were successful. Moreover, this research offers approaches to counteract the loss of attractiveness of OU.

[Daily routine in orthopedics and traumatology - results of a nationwide survey of residents]. / Der klinische Alltag in Orthopädie und Unfallchirurgie - Ergebnisse einer nationalen Umfrage unter Assistenzärzten in O und U.

BACKGROUND: The subject orthopedics and traumatology suffers by a loss of attractiveness which results in a lack of young blood. The aim of this study of the Youth Forum of the German Society of Orthopedics and Traumatology (DGOU) is to register the working conditions of residents in orthopedics. MATERIAL AND METHODS: In the months September and October 2013 we performed a survey on members of the following German societies: German Society of Orthopedics and Traumatology (DGOU), German Society of Traumatology (DGU) and the German Society of Orthopedics and Orthopedic Surgery (DGOOC), (age < 40). Our questionnaire includes 15 questions. RESULTS: We achieved 28,9 % (n = 331) answered questionnaires. The mean working time per week is 55 hours. 73 % of all participants do more than 5 emergency services per month. 52 % are more than 3 times on duty for 24 hours. Only 13 % of all residents have well ordered working hours. Normally working time is divided into three parts: one third for bureaucracy, one for operation theatre and the last for other activities (e.g. ward round). 35,6 % do only one surgery per week, 12 % do not perform any surgeries. An annual report is performed only in 45 %. A structured concept of training only exists in 16 % of all hospitals. In addition to clinical work 45 % are involved in scientific projects, mostly in their spare-time. Finally 58 % of all surgeons would still recommend orthopedics and traumatology. CONCLUSION: In order to maintain orthopedics and traumatology as an attractive it is necessary to implement flexible working time models and to reorganize and improve training-concepts.

Correct positioning of pedicle screws with a percutaneous minimal invasive system in spine trauma.

BACKGROUND: When performing minimally invasive spine surgery in trauma patients, a short operation time and a perfect positioning of pedicle screws are demanded. In this study, we show that a Minimally Invasive Pedicle Screw System allows both. METHODS: One hundred and twenty-one patients (131 fractures) with fractures between Th 3 and L 5 were treated. The most common fracture type was A3. We treated 52 females and 69 men with a mean age of 56.7 years. In 72% of the cases, the procedure was performed by two experienced spine surgeons. Postoperatively, all patients were examined using a CT-scan. In 61 patients, an anterior stabilization was additionally performed in 33 patients, vertebroplasty or cyphoplasty was performed. Fifteen patients underwent laminectomy. RESULTS: No patient postoperatively developed any additional neurological compromise. In total, 682 screws were placed. In the postoperative CT-scan, we found 16 screws (2.2%) in suboptimal position, 8 with medial and 8 with lateral deviation. DISCUSSION: With the Minimally Invasive Pedicle Screw System used in this study, spinal fractures can be treated in a short operation time with percutaneous stabilization and a correct positioning of the pedicle screws in almost 98%. In our study, no screw was so much malpositioned that revision surgery would have been necessary. LEVEL OF EVIDENCE: Level III - Case-control study.

[Periprosthetic fractures of the knee joint]. / Periprothetische Frakturen des Kniegelenks.

Periprosthetic fractures are a challenging problem in view of the demographic development and the increasing number of implanted prostheses. Most of these fractures occur postoperatively after a period of two to four years after implantation of a total knee arthroplasty. They are usually caused by traumata, implantation-specific factors and loosening of the prosthesis. Beside further risk factors osteopenia and a reduced mobility of the prosthesis predispose to these fractures. Numerous classifications which also include a loosening of the prosthesis in the fracture discription are an important tool for planning the therapy. Beside the conservative treatment, the stabilization of the fracture or changing the prosthesis should be considered. The treatment options of periprosthetic fractures of the knee joint are discussed in view of different initial situations with the aim of achieving a load-stable situation.