First aid and basic life support: a questionnaire survey of medical schools in the Netherlands.

PURPOSE: Adequate education in first aid and basic life support (BLS) should be considered as an essential aspect of the medical curriculum. The objective of this study was to investigate the current medical training in first aid and BLS at all 8 medical schools in the Netherlands. SUMMARY: An evaluation was made, by sending a questionnaire to all medical schools, regarding whether the medical training was performed in accordance with the national Dutch guidelines for medical education. The response was 100%. Seven of the eight medical schools train their students in first aid and BLS during the medical curriculum. An average of only 38% of the clinical pictures and diseases and 69% of the skills were mastered at the level-defined national Dutch guidelines. CONCLUSION: The medical education in the Netherlands does not meet the required objectives as stated in the national Dutch guidelines concerning first aid and BLS.

Validation of two methods to measure posterior tilt in femoral neck fractures.

INTRODUCTION: Posterior tilt of the femoral head in femoral neck fractures (FNF) may influence stability of the fracture and may therefore affect the treatment outcome. Posterior tilt can be measured with different methods. The Lateral Garden Angle (LGA) has been used for this purpose for decades and more recently the Posterior Tilt Measurement (PTM) was introduced. Despite the fact that both methods (LGA and PTM) are used in multiple studies, they have never been compared for reliability in a direct study. The aim of this study is to analyze the intra and inter observer reliability of the LGA described by Garden and the PTM according to Palm. METHODS: Four observers measured the posterior tilt on the radiographs of 50 FNF two times with both methods. Intra and inter observer reliability were determined for the LGA and the PTM. RESULTS: The intra observer reliability for both methods is substantial with an intra class coefficient of 0.75. The inter observer reliability of the PTM is also substantial with an intra class coefficient of 0.75 compared to a moderate reliability of the LGA with an intraclass coefficient of 0.60. CONCLUSION: Based on our results we believe the LGA and the PTM are both reliable methods to measure posterior tilt. Yet the Posterior Tilt Measurement seems to have a better inter observer reliability and therefore has a slight preference over the Lateral Garden Angle.

[Walking in the sun: heat stroke and heat exhaustion during the Four-Day March in Nijmegen, in 2006]. / Wandelen in de zon: hitteberoerte en hitte-uitputting tijdens de Nijmeegse Vierdaagse 2006.

The annual Four-Day March in Nijmegen, The Netherlands, in July 2006 was cancelled after the first day because two participants had died, men aged 65 and 57 years, and many had become unwell while walking in unusually high ambient temperatures. However, the cause of death of the two who died turned out to be cardiovascular and not heat-related. The case of two of the people that became unwell, men aged 58 and 59 years, respectively, shows that heat stroke and heat exhaustion were important causative conditions. Heat-related illnesses are relatively uncommon in the Netherlands due to its temperate climate. Heat stroke is the most severe of these and associated with a high mortality rate if not recognised and treated promptly. The primary cause is accumulation of heat due either to diminished loss or increased endogenous heat production, such as by physical exertion. Heat exhaustion is caused by salt or water depletion.

[Protocols for trauma care and the missing of injuries in severely injured accident victims during the prehospital phase]. / Protocollering van traumazorg en het missen van letsels bij ernstig gewonde ongevalspatiënten in de prehospitale fase.

Standardizing trauma care according to internationally accepted life-support principles is being increasingly implemented in the prehospital as well as the intramural setting. In the primary survey it is important to distinguish between aspects of major and minor importance, without losing sight of details. In prehospital care it is of little use to be focused on the complete diagnoses and the approach should be related to signs and symptoms. First attention should be paid to the mechanism of injury, related potential vital impairment and obvious visible injuries. The goal should be effective treatment, focused on the stabilization of vital functions and triage related to the choice of facility necessary for definitive care.

[Navigation surgery and fracture treatment]. / Navigatiechirurgie en fractuurbehandeling.

During operative fracture treatment the surgeon depends on fluoroscopic or X-ray radiological images as well as CT scans or MRI scans. This means that the surgeon sees only images at a given moment. Continuous imaging is technically complex and is accompanied by considerable exposure to radiation. Between images the surgeon has to depend on his or her knowledge of anatomical relationships and three-dimensional orientation. This may lead to the incorrect positioning of implants with ensuing morbidity and sometimes even death. Throughout the surgical procedure, computer assisted surgery (CAS) informs the surgeon of the exact position of the instruments in relation to the affected bone. The concept can be compared to that of the global positioning system (GPS) that is used by motorists. Clinical applications of CAS have been described for the operative treatment of vertebral fractures as well as fractures of the pelvis, hip and long bones. In reconstructive surgery, CAS is used for positioning the patient for total hip and knee surgery. The potential advantages of CAS are: increased accuracy, safety and reproducibility combined with lower radiation levels. Currently CAS is not widely used. There are a number of reasons for this. The technique is expensive and complex although the newer systems are more user friendly. It is possible that in the future CAS will be in standard use in orthopaedic and trauma surgery.

[Damage control surgery in polytraumatized patients]. / 'Damage control surgery' bij polytraumapatiënten.

Care for the polytraumatized patient in the pre-hospital phase has improved rapidly in recent years. This has resulted in more patients being alive on arrival at the hospital. The treatment of polytraumatized patients requires a different approach to that of regular trauma patients because they are threatened not only by the injuries themselves but also by the metabolic disruptions that follow. Therefore, the concept of damage control surgery (DCS) has been developed with the primary aim of controlling the life-threatening situation without immediate definitive repair of the sustained injuries. DCS describes a triphasic approach for abdominal and thoracic injuries and for injuries of the pelvic and extremities. The first phase aims at surgical intervention to stop the bleeding and to prevent further contamination. The second phase consists of resuscitation on the Intensive Care Unit and the third phase aims at definitive repair of the sustained injuries. Despite the low level of evidence found in the literature, DCS seems to reduce mortality rates in polytraumatized patients. Therefore, when initiated correctly and at the right moment, it appears to be a promising technique.

Incidence and prognostic factors of chronic pain after isolated musculoskeletal extremity injury.

BACKGROUND: Chronic pain in patients is usually related to an episode of pain following acute injury, emphasizing the need to prevent progression from acute to chronic pain. Multiple factors in the acute phase might be responsible for perpetuating the pain. The presentation of patients at the emergency department (ED) presents a prime opportunity to identify patients at high risk for chronic pain and to start appropriate treatment. METHODS: The PROTACT study is a prospective follow-up study aiming to estimate the incidence and prognostic factors responsible for the development of chronic pain after musculoskeletal injury. Data including sociodemographic, pain, clinical, injury- or treatment-related and psychological factors of 435 patients were collected from registries and questionnaires at ED visit, 6-week, 3- and 6-month follow-up. RESULTS: At 6 months post-injury, 43.9% of the patients had some degree of pain (Numeric Rating Scale (NRS) ≥1) and 10.1% had chronic pain (NRS ≥4). Patients aged over 40 years, in poor physical health, with pre-injury chronic pain, pain catastrophizing, high urgency level and severe pain at discharge were found to be at high risk for chronic pain. CONCLUSIONS: Two prognostic factors, severe pain at discharge and pain catastrophizing, are potentially modifiable. The implementation of a pain protocol in the ED and the use of cognitive-behavioural techniques involving reducing catastrophizing might be useful.

Posterolateral dislocation of the elbow joint. Relationship to medial instability.

BACKGROUND: Dislocation of the elbow joint is the second most common dislocation in the upper extremity, dislocation of the shoulder being the most common. It has been reported that uncomplicated dislocation of the elbow joint may be associated with a decreased range of motion, degenerative changes in the elbow joint, ectopic calcification, or neurological deficits. As the medial collateral ligament complex can be completely disrupted during dislocation, we evaluated the association between the long-term results of treatment of simple posterolateral dislocation of the elbow and the presence of persistent medial or valgus elbow instability. METHODS: Fifty patients who had a mean age of thirty-three years (range, eighteen to fifty-eight years) had closed reduction of a posterolateral dislocation of the elbow without associated fractures. The extremity was immobilized in an above-the-elbow plaster cast for three weeks. After a mean duration of follow-up of nine years (range, six to thirteen years), forty-one patients were evaluated with an interview, a physical examination, and radiographs made while a valgus load was applied to the elbow. RESULTS: The average score according to the system of The Hospital for Special Surgery was 91 points (range, 49 to 100 points), and thirty-one patients described their elbow function as good or excellent. Twenty-four patients had evidence of medial instability on radiographs made while a valgus load was applied to the elbow. Twenty-one patients had signs of degeneration of the joint, and twenty-five patients had ectopic ossification. Magnetic resonance imaging combined with arthrography was performed for the first twenty patients; eight had evidence of rupture of the medial collateral ligament, seven had generalized degenerative changes of the cartilage, and four had a chondral defect of the capitellum. (The study could not be completed for the remaining patient.) Medial instability on radiographs was correlated with signs of degeneration (p = 0.001), ectopic ossification (p = 0.01), a worse score according to the system of The Hospital for Special Surgery (p = 0.002), and persistent pain (p = 0.04). CONCLUSIONS: Posterolateral dislocation of the elbow joint can lead to persistent valgus instability that is associated with a worse overall clinical and radiographic result.

Degenerative changes at the knee and ankle related to malunion of tibial fractures. 15-year follow-up of 88 patients.

We re-examined clinically and radiologically 88 patients with a fracture of the lower leg at a mean follow-up of 15 years. Forty-three fractures (49%) had healed with malalignment of at least 5 degrees. More arthritis was found in the knee and ankle adjacent to the fracture than in the comparable joints of the uninjured leg. Malaligned fractures showed significantly more degenerative changes. Eighteen patients (20%) had symptoms in the fractured leg. There was a significant correlation between symptoms in the knee and arthritis but not between symptoms and ankle arthritis or malalignment. We conclude that fractures of the lower leg should be managed so that the possibility of angular deformity and thereby late arthritis is minimised.

Treatment of unstable trochanteric fractures. Randomised comparison of the gamma nail and the proximal femoral nail.

The proximal femoral nail (PFN) is a recently introduced intramedullary system, designed to improve treatment of unstable trochanteric fractures of the hip. In a multicentre prospective clinical study, the intra-operative use, complications and outcome of treatment using the PFN (n = 211) were compared with those using the gamma nail (GN) (n = 213). The intra-operative blood loss was lower with the PFN (220 ml v 287 ml, p = 0.001). Post-operatively, more lateral protrusion of the hip screws of the PFN (7.6%) was documented, compared with the gamma nail (1.6%, p = 0.02). Most local complications were related to suboptimal reduction of the fracture and/or positioning of the implant. Functional outcome and consolidation were equal for both implants. Generally, the results of treatment of unstable trochanteric fractures were comparable for the PFN and GN. The pitfalls and complications were similar, and mainly surgeon- or fracture-related, rather than implant-related.

Biomechanical comparison of sacroiliac screw techniques for unstable pelvic ring fractures.

OBJECTIVE: To determine the stiffness and strength of various sacroiliac screw fixations to compare different sacroiliac screw techniques. DESIGN: Randomized comparative study on embalmed human pelvises. MATERIALS AND METHODS: In 12 specimens, we created a symphysiolysis and sacral fractures on both sides. Each of these 24 sacral fractures was fixed with 1 of the following methods: 1 sacroiliac screw in the vertebral body of S1, 2 screws convergingly in S1, or 1 screw in S1 and 1 in S2. On the left and right side of a pelvis, different techniques were used. The pubic symphysis was not stabilized. We measured the translation and rotation stiffness of the fixations and the load to failure using a 3-dimensional video system. RESULTS: The stiffness of the intact posterior pelvic ring was superior to any screw technique. Significant differences were found for the load to failure and rotation stiffness between the techniques with 2 screws and a single screw in S1. The techniques utilizing 2 screws showed no differences. CONCLUSIONS: Based on the results of this study, we can conclude that a second sacroiliac screw in completely unstable pelvic fractures increases rotation stiffness and improves the load to failure.

Emergency ambulance assistance in The Netherlands: is the Dutch situation optimal?

The system of prehospital trauma care in the Netherlands is the subject of great concern. Although many improvements have been achieved in the last decade, there are still some deficits. Legislation concerning the minimal level of education for ambulance attendants was recently upgraded to 'registered nurse', a standard which must be achieved by 1997. Standardization with regard to extrication techniques, equipment and methods of treatment in prehospital trauma care does not yet exist. Although aware of the fact that large regional differences exist throughout the USA, a system of care in accordance with the advanced trauma life support (ATLS) standard of the American College of Surgeons (ACS) and by means of prehospital and advanced trauma life support (PHTLS) given according to the standards of the National Association of Emergency Medical Technicians (NAEMS) was considered to be the 'golden standard'. Nineteen ground ambulance and two helicopter services in different states of the USA, working according to ACS/NAEMS standard, were visited to analyse the system of care, with special reference to (para)medical education, communication, logistics, and immobilization materials and techniques. In the Netherlands all 41 central post ambulance services (CPAs) were asked to return a questionnaire. This resulted in a 90% (37 out of 41) response. The deficits of the Dutch system of care related to the PHTLS/ATLS standard are pointed out, resulting in recommendations to improve the Dutch system. The requirements of the dispatcher are far inferior to the optimal situation, which, together with the lack of technical equipment, results in serious communication problems. The Dutch ambulance attendant education, in which in the present system the education level reaches 'registered nurse' in only 91% and specialized courses are not mandatory, should be upgraded to the PHTLS level of care.

Changes in the diagnosis and treatment of traumatic splenic rupture: a retrospective analysis of 99 consecutive cases.

From January 1986 to January 1995, 99 consecutive cases with a ruptured spleen were analysed retrospectively. Diagnostic peritoneal lavage was replaced by abdominal ultrasound as a routine screening investigation in blunt abdominal trauma after 1991. An abdominal computed tomography scan carried out in stable circulatory conditions provided additional information in 80% of the cases. The choice of treatment was related to the extent of the splenic damage and associated injuries. Even in degree IV ruptures splenorrhaphy was carried out successfully in 38% (five out of 12). The Hospital Trauma Index-Injury Severity Score (HTI-ISS) was significantly lower (17.7; n = 43) in conservative treatment than in cases treated by splenorrhaphy (27.6; n = 25) or splenectomy (33.6; n = 31). Conservative treatment (n = 43) resulted in a secondary intervention in 19%, whereas primary splenorrhaphy (n = 25) failed once (4%). Clinical morbidity was 26%, with no significant differences between conservative treatment, splenorrhaphy and splenectomy. Early mortality (0-30 days post-trauma) reached 14%, and was related to extensive injuries in all cases. The mean HTI-ISS in patients with a fatal outcome was 50.5. Overall, 62% of the injured spleens were saved, with the rate of splenic preservation improving throughout the study period. A conservative policy was increasingly treatment of first choice in patients with stable circulatory parameters with major concomitant injuries.

Pitfalls in penetrating trauma.

In Western Europe the most frequent cause of multiple injuries is blunt trauma. Only few of us have experience with penetrating trauma, without exception far less than in the USA or South-Africa. In Rotterdam, the Erasmus Medical Centre is a level I trauma centre, situated directly in the town centre. All penetrating traumas are directly presented to our emergency department by a well organized ambulance service supported by a mobile medical team if necessary. The delay with scoop and run principles is very short for these cases, resulting in severely injured reaching the hospital alive in increasing frequency. Although the basic principles of trauma care according to the guidelines of the Advanced Trauma Life Support (ATLS) (1-2) are the same for blunt and penetrating trauma with regard to priorities, diagnostics and primary therapy, there are some pitfalls in the strategy of management in penetrating trauma one should be aware of. Simple algorithms can be helpful, especially in case of limited experience (3). In case of life-saving procedures, the principles of Damage Control Surgery (DCS) must be followed (4-5). This approach is somewhat different from "traditional" surgical treatment. In the Ist phase prompt interventions by emergency thoracotomy and laparotomy are carried out, with only two goals to achieve: surgical control of haemorrhage and contamination. After temporary life-saving procedures, the 2nd phase is characterized by intensive care treatment, dealing with hypothermia, metabolic acidosis and clotting disturbances. Finally in the 3rd phase, within 6-24 hours, definitive surgical care takes place. In this overview, penetrating injuries of neck, thorax, abdomen and extremities will be outlined. Penetrating cranial injuries, as a neurosurgical emergency with poor prognosis, are not discussed. History and physical examination remain the corner stones of good medical praxis. In a work-up according to ATLS principles airway, breathing and circulation should be evaluated with great care. Neurovascular examination related to trauma of the spinal cord, peripheral nerves as well as vascular involvement should be carried out also in extremity injuries. Physical examination should be completed by localization of all stabwounds, in- and outshot openings as well as recto-vaginal examination and inspection of the oropharynx.

[Scientific research in trauma care; an advisory report from the Health Research Council of the Netherlands]. / Wetenschappelijk onderzoek in de traumazorg; een advies van de Raad voor Gezondheidsonderzoek.

Within the medical sciences, traumatology is a relatively under-researched field. The Health Research Council of the Netherlands [Dutch: Raad voor Gezondheidsonderzoek; RGO] has issued an advisory report to the Minister of Health, Welfare and Sport aimed at reducing this shortfall in the coming years. The advisory report recommends that a specific budget is set apart for traumatology research. The assessment and selection of research submissions must have a strong subject-specific component. Innovative areas within the subject need to be chosen, for which the RGO has formulated recommendations. With this administrative breakthrough in the area of funding provision, the opportunity for research groups to carry out structured research has been created. If these recommendations are followed, then the subject specialists will face the challenge of taking the next step.

['Advanced trauma life support' in Netherlands]. / 'Advanced trauma life support' in Nederland.

Introduction of the principles of advanced trauma life support (ATLS) in the management of accident victims has been in progress in the Netherlands since 1995. The main ATLS principles are that the aid giver treats the most dangerous disorder first and does no further damage. After assessment and, if necessary, treatment of the airways, the respiration, the circulation and any craniocerebral injury, an exploratory examination is carried out. Physicians receive theoretical and practical instructions in this form of management during an intensive two-day course, counselled by a coordinating organization in the USA. Most of those attending are interns in general surgery, traumatology and orthopaedics, gatekeeper doctors of emergency rooms and army medical officers. The standardized way of thinking improves the communication and understanding between the various disciplines involved in trauma care, in part because there exist comparable programmes for ambulance care and emergency care. Other measures improving the quality of trauma care are regionalization of the trauma care, medical helicopter teams and evaluation of the effects of ATLS as an operating procedure.

[Disaster medicine: lessons from Enschede and Volendam]. / Rampengeneeskunde: lessen uit Enschede en Volendam.

Two major disasters hit the Netherlands recently: on May 13th 2000, a local fireworks depot exploded in the middle of the city of Enschede and on New Year's Eve 2001, fire destroyed a pub full of people in Volendam. Lessons from the involvement of medical services in these disasters include: disaster medicine must be seen as an extension of emergency care. Hospital staff should be familiar with the procedures in case of a disaster, and regular practice on a regular basis is mandatory. Logistics, as well as individual care of the victims, differ in detail from everyday practice, notably during the first hour following the disaster. Attention should be paid to the provision of psychological aftercare soon after the event for the victims and their families, as well as for health care workers.

[Quantification of excessive length of hospital stay ('wrong bed problem'); hip fractures in the elderly]. / Kwantificering van te langdurige ziekenhuisopname ('verkeerde-beddenproblematiek'); heupfracturen bij bejaarden.

OBJECTIVE: To assess the magnitude of hospital bed misoccupation by elderly patients admitted because of a hip fracture. DESIGN: Prospective clinical study. SETTING: Department of surgery-traumatology of Leiden University Hospital, the Netherlands. METHOD: All patients with a hip fracture admitted from January 1991 to April 1993 were registered for age, ability level, pre-existent disease, housing situation, social environment, morbidity, mortality and duration of hospital stay. The misexploitation of hospital beds was calculated based on an optimal hospital stay of 9 days. When complications occurred, necessitating longer medical treatment, this optimum was adjusted in each individual case. RESULTS: The mean hospital stay in 123 patients who had to be transferred to a nursing home when they had previously lived in their own homes or in an old people's home was 23.8 days, and 11.6 days above the optimum; for patients who could return to their previous housing situation these figures were 13.5 and 4.2 respectively (p < or = 0.05). Age, ability level, pre-existent disease and less importantly the social environment influenced the possibilities for a patient to return to his/her own home. Use of a clinimetric scale, which objectively assessed the probability of resocialisation, decreased the mean hospital stay from 28-30 days to less than 17. CONCLUSION: To minimize the duration of unnecessary hospital stay, use of a clinimetric scale on admission to assess the probability of rapid resocialisation can be useful.

[Sperm analysis following vasectomy: when to perform a revasectomy?]. / Sperma-analyse na vasectomie: wanneer revasectomie?

PIP: On the basis of 4406 sperm analyses performed for check-up after vasectomy in 3150 men, a retrospective study was made of the question of what sperm control policy is recommended. Sperm tests after 10 ejaculations after operation revealed abolished fertility in almost 90% of the men, so that no further checks were indicated. When the first test shows more than 0.1 x 10 6 nonmotile spermatozoa/ml, continued check-ups are necessary until infertility has been proven. Motile spermatozoa during the first 6 months postvasectomy do not as a rule constitute a sign of recanalization but rather of the presence of a residue higher up in the urogenital tract. During this period, revasectomy therefore is not indicated. True recanalization occurs later and has been encountered only once among our 3150 patients. (author's)^ieng