Forty Years on From an Event That Changed the Management of Trauma Around the World: What Actually Happened That Night Forty Years Ago?

The management of trauma has evolved significantly over the last 40 years. Seminal to this process was the development in Nebraska of a concept of trauma management that was promulgated as Advanced Trauma Life Support (ATLS). It has achieved global support and is considered by many to be the acme in trauma management. Every participant in an ATLS course remembers that an aviation accident in rural Nebraska was responsible for the nascence of the program but very few know the details of the crash. February 17, 2016, was the 40th anniversary of the accident. This article extracts the details of the flight, the crash, the search, the extrication, the reception at the nearby rural hospital, and the injuries from both the official report and the published, personal records of survivors of the crash. The effect of ATLS can be debated elsewhere and its future questioned. However, the article concludes by highlighting the fortitude and resilience of the human spirit that were demonstrated that night under incredible circumstances.

An English admiral and an American aviator: advanced trauma life support and two historical military casualties.

This article considers two historical military casualties in the context of present day Advanced Trauma Life Support (ATLS) teaching. The death of Admiral Lord Nelson, Royal Navy, at the Battle of Trafalgar in 1805 has been well documented while that of Lieutenant Luke, an American aviator, U.S. Army Air Service, in France in 1918 has been almost disregarded. Both suffered a gunshot wound to the chest with the responsible weapon similarly sited. Nelson's dying was witnessed and recorded in detail by his surgeon. Luke's death was unwitnessed and has been the subject of considerable speculation. A recent monograph removes much of this speculation but cannot describe his last few minutes of life. This article describes both events and considers the mechanism of injury. It presents speculative radiological reconstructions and an outline of emergency management according to ATLS for both and further clinical speculation on Luke's demise.

Safety and efficacy of nontherapeutic male circumcision: a systematic review.

PURPOSE: We wanted to assess the safety and efficacy of nontherapeutic male circumcision through a systematic review of the literature. METHODS: We systematically searched The York Centre for Reviews and Disseminations, Cochrane Library, PubMed, and EMBASE databases for randomized controlled trials published between January 1997 and August 2008. Studies reporting on circumcision in an operative setting in males of any age with no contraindications to or medical indications for circumcision were eligible for inclusion. The main comparator was intact genitalia. From 73 retrieved studies, 8 randomized controlled trials were ultimately included for analysis. RESULTS: Severe complications were uncommon. Analgesia/anesthesia during circumcision was promoted. The prevalence of self-reported genital ulcers was significantly lower in circumcised men than uncircumcised men (3.1% vs 5.8%; prevalence risk ratio 0.53; 95% confidence interval [CI], 0.43-0.64; P<.001). Circumcised sub-Saharan African men were at significantly lower risk of acquiring human immunodeficiency virus/acquired immune deficiency syndrome than were uncircumcised men (random effects odds ratio = 0.44, 95% CI, 0.32-0.59; P <.001). The evidence suggests that adult circumcision does not affect sexual satisfaction and function. CONCLUSIONS: Strong evidence suggests circumcision can prevent human immunodeficiency virus/acquired immune deficiency syndrome acquisition in sub-Saharan African men. These findings remain uncertain in men residing in other countries. The role of adult nontherapeutic male circumcision in preventing sexually transmitted infections, urinary tract infections, and penile cancer remains unclear. Current evidence fails to recommend widespread neonatal circumcision for these purposes.

Nontherapeutic male circumcision: tackling the difficult issues.

INTRODUCTION: Male circumcision is the most commonly performed surgical procedure in the world. Circumcision may be performed to treat an underlying pathological process ("therapeutic circumcision"). However there may be religious, cultural, and social indications. AIM: This article addresses the religious, cultural, social, and ethical issues surrounding nontherapeutic male circumcision (NTMC). MAIN OUTCOME MEASURES: Any religious, social, cultural, or ethical issues relating to NTMC. METHODS: Because of the absence of high level evidence, a concise literature review was undertaken to identify articles published between January 1990 and February 2009 summarizing current knowledge on NTMC. RESULTS: There are complex religious, cultural, social, and prophylactic incentives for NTMC. The procedure may have associated clinical and psychosocial adverse events and raises such ethical issues as bodily integrity and consent. Because of the strength of the incentives for NTMC, there may be important implications in denying patients the procedure. Several important issues must be considered when introducing mass circumcision as a preventative strategy for HIV/AIDS. CONCLUSION: When assessing whether NTMC will benefit or harm a patient, clinicians must take his religious, cultural, and social circumstances into account. Males requiring mandatory religious or cultural NTMC are likely to suffer significant harm if they do not receive circumcision and should be considered separately to males in general.

Painless obstructive jaundice secondary to a common bile duct abscess: a delayed sequela of cholecystectomy.

Complications related to cholecystectomy are well described. Most occur in the early postoperative period and are recognised either at the time of, or shortly after surgery. Clinical sequelae occurring years following cholecystectomy are rare and infrequently reported. In addition, most delayed complications are related to the continuing presence or new formation of gallstones. In this paper we present a unique case of an abscess of the common bile duct wall, presenting with painless obstructive jaundice more than 30 years following an open cholecystectomy, without the presence of gallstones. The clinical presentation, investigations, and treatment are discussed with a review of other relevant reported cases in the literature.

The impact of the ILCOR 2005 CPR guidelines on a physical fitness assessment: a comparison of old and new protocols.

OBJECTIVE: St. John Ambulance Australia has used the performance of CPR for 10 min as a fitness test for its members. Recent changes in international guidelines for cardiopulmonary resuscitation caused concern that the new ILCOR protocol was more strenuous than the previous one. This study compared the two protocols to determine if there were significant differences and to allow an evidence-based decision on the continuation or modification of this practice. MATERIALS AND METHODS: We studied 26 subjects performing single-rescuer cardiopulmonary resuscitation on a manikin. Every subject did 10 min cardiopulmonary resuscitation using each protocol. The study used a randomized cross-over design. The estimated maximum heart rate was calculated for each subject. Compression rate and effective ventilation (number and depth) were enforced by direct feedback. Subjective and objective measures of physical activity were recorded at regular intervals. RESULTS: The maximum percentage of estimated maximum heart rate achieved during 15:2 and 30:2 CPR was 76+/-2% and 79+/-2%, respectively (mean+/-standard error of mean; P<0.001). The rate pressure product at the end of 10 min cardiopulmonary resuscitation was 18,999+/-891 for 15:2 and 19,204+/-757 for 30:2 (ns) while the Borg rating of perceived exertion was 13.7+/-0.5 for 15:2 and 14.8+/-0.5 for 30:2 (P<0.05). CONCLUSION: The new protocol increases both objective and subjective measures of effort. While the absolute differences in workload are small, they are statistically significant. There are significant indicators of this difference in the first 3 min of assessment. Rescuers are more likely to be operating at a high-level of physical activity. To avoid increasing the demands of its mandatory fitness test, St. John should reduce the required performance time from its present 10 min.

Acquiring and maintaining competence in the application of extrication cervical collars by a group of first responders.

INTRODUCTION: Research on skill acquisition and retention in the prehospital setting has focused primarily on resuscitation and defibrillation. Investigation into other first aid skills is required in order to validate practices and support training regimes. No studies have investigated competency using an extrication cervical collar for cervical spine immobilization. OBJECTIVE: This study was conducted to confirm that a group of first responders could acquire and maintain competency in the application of an extrication cervical collar over a 12-month period. METHODS: Participants attended a standardized training session that addressed the theory of application of an extrication cervical collar followed by hands-on practice. The training was presented by the same instructor and covered the nine key elements necessary in order to be deemed competent in extraction cervical collar application. Following the practical session, the competency of the participants was assessed. Participants were requested not to practice the skill during the 12-month period. Following the 12-month period, their skills were re-assessed by the same assessor. RESULTS: Of the 64 subjects who participated in the study, 100% were competent after the initial first assessment. Forty-one participants (64%) were available for the second assessment (12 months later); of these, 25 (61%) maintained competence. CONCLUSIONS: Although the sample size was small, this research demonstrates that first responders are able to acquire competence in applying an extrication cervical collar. However, skill retention in the absence of usage or re-training is poor. Larger studies should be conducted to validate these results. In addition, there is a need for research on the clinical practice and outcomes associated with spinal immobilization in the prehospital setting.

Team Echo: observations and lessons learned in the recovery phase of the 2004 Asian tsunami.

The 26 December 2004 Tsunami resulted in a death toll of >270,000 persons, making it the most lethal tsunami in recorded history. This article presents performance data observations and the lessons learned by a civilian team dispatched by the Australian government to "provide clinical and surgical functions and to make public health assessments". The team, prepared and equipped for deployment four days after the event, arrived at its destination 13 days after the Tsunami. Aspiration pneumonia, tetanus, and extensive soft tissue wounds of the lower extremities were the prominent injuries encountered. Surgical techniques had to be adapted to work in the austere environment. The lessons learned included: (1) the importance of team member selection; (2) strategies for self-sufficiency; (3) personnel readiness and health considerations; (4) face-to-face handover; (5) coordination and liaison; (6) the characteristics of injuries; (7) the importance of protocols for patient discharge and hospital staffing; and (8) requirements for interpreter services. Whereas disaster medical relief teams will be required in the future, the composition and equipment needs will differ according to the nature of the disaster. National teams should be on standby for international response.

Team Echo: Observations and Lessons Learned in the Recovery Phase of the 2004 Asian Tsunami.

The 26 December 2004 Tsunami resulted in a death toll of >270,000 persons, making it the most lethal tsunami in recorded history. This article presents performance data observations and the lessons learned by a civilian team dispatched by the Australian government to "provide clinical and surgical functions and to make public health assessments". The team, prepared and equipped for deployment four days after the event, arrived at its destination 13 days after the Tsunami. Aspiration pneumonia, tetanus, and extensive soft tissue wounds of the lower extremities were the prominent injuries encountered. Surgical techniques had to be adapted to work in the austere environment. The lessons learned included: (1) the importance of team member selection; (2) strategies for self-sufficiency; (3) personnel readiness and health considerations; (4) race-to-face handover; (5) coordination and liaison; (6) the characteristics of injuries; (7) the importance of protocols for patient discharge and hospital staffing; and (8) requirements for interpreter services. Whereas disaster medical relief teams will be required in the future, the composition and equipment needs will differ according to the nature of the disaster. National teams should be on standby for international response.

Latex allergy in the prehospital setting.

INTRODUCTION: Latex allergy first was recognized early in the 20th Century, but was not a matter of concern until the last decade of that Century. The reported incidence of latex allergy in different occupations varies considerably. It has been documented in dental workers, operating theater staff, anesthetists, and laboratory technicians. However, little data specifically related to those involved in patient care in the emergency prehospital setting are available. METHODS: A questionnaire was distributed to a sample of both volunteer and salaried first responders from St. John Ambulance Australia in South Australia and Western Australia, and the South Australian Ambulance Service. The first responders were surveyed to: (1) determine the incidence of latex allergy; (2) consider possible factors associated with its development; (3) compare characteristics of the surveyed groups; and (4) reinforce the development of an educational program. The study tool had predetermined statistical qualities. Data were collated and processed using standard statistical procedures. Surveys were collected anonymously. RESULTS: Of the 2,716 forms distributed, 1,099 were returned, resulting in an overall response rate of 40.5%. Atopy was identified in 14.9% of participants, hand dermatitis in 9.4%, and latex allergy in 6.4%. In the group of full-time ambulance officers, there was a significantly higher incidence of hand dermatitis and latex allergy. There also was a significant relationship between latex allergies and both dermatitis and glove usage (as measured by frequency and duration). CONCLUSION: In a group of first responders assessed by an anonymous, voluntary questionnaire, the subset of full-time, salaried ambulance officers was identified as having a higher incidence of hand dermatitis and latex allergy than their volunteer co-workers. These results require further assessment to substantiate the frequency of latex allergy and determine the predisposing factors. All personnel must learn about hand care. Non-powdered, natural rubber latex gloves should be supported for general use in this setting.

A systematic review of laparoscopic live-donor nephrectomy.

BACKGROUND: A systematic review was undertaken to assess the safety and efficacy of laparoscopic live-donor nephrectomy (LLDN) compared with open live-donor nephrectomy (OLDN). METHODS: Literature databases were searched from inception to March 2003 inclusive. Comparative studies of LLDN versus OLDN (randomized and nonrandomized) were included. RESULTS: There were 44 included studies, and the quality of the available evidence was average. There was only one randomized controlled trial and six nonrandomized comparative studies with concurrent controls identified. In terms of safety, for donors, there did not seem to be any distinct difference between the laparoscopic and open approaches. No donor mortality was reported for either procedure, and the complication rates were similar although the types of complications experienced differed between the two procedures. The conversion rate for LLDN to an open procedure ranged from 0% to 13%. In terms of efficacy, LLDN seemed to be a slower operation with longer warm ischemia times than OLDN, but this did not seem to have resulted in increased rates of delayed graft function for recipients. Donor postoperative recovery and convalescence seemed to be superior for LLDN, making it a potentially more attractive operation for living donors. Although in the short-term, graft function and survival did not seem to differ between the two techniques, long-term complication rates and allograft function could not be determined and further long-term follow-up is required. CONCLUSIONS: LLDN seems to be at least as safe and efficacious as OLDN in the short-term. However, it remains a technique in evolution. Further high-quality studies are required to resolve some of the outstanding issues surrounding its use, in particular, long-term follow-up of donor complications and recipient graft function and survival.