102 Injury, 4, 102-105

Accident services in Switzerland

M. Allgawer Btirgerspital, Bade

ACCIDENT surgery is concerned with injuries to all systems at all ages of life-in fact, it involves treating the injured skin of man and its total contents.

In Switzerland 1.7 million workers are insured with the Swiss Accident Insurance, and accidents occurring at work are registered separately from those occurring away from work. The mortality per thousand accidents is 4.7 per cent for non- occupational injuries and only 1.7 per cent for those sustained at work. Leisure has thus become more dangerous than work. Accident prevention in industry is easier than reducing injuries among homo ludens. For every million insured persons, about 800,000 accidents are recorded in a five-year period. For a million active workers, 1250 beds are needed to cope with accident cases in Switzerland.

If all available methods could be assembled to deal with accident cases, it would probably be possible to reduce the time spent as in-patients by 30 per cent, which would be an enormous economy. It is the duty of surgeons to attempt to achieve this objective.

Management in accident surgery can be con- sidered under two headings:-

1. The medical treatment. 2. Appropriate organizations.

The main progress in accident treatment has involved ‘ surgical intensive medicine ‘, a title which has been deliberately chosen since the normal phrase ‘ intensive care or therapy ’ neglects the important prophylactic measures that can be made use of. Intensive medical treatment requires skilled knowledge and tech- niques and can be considered under the following headings :-

a. Appropriate knowledge of surgical tech- niques and postoperative care and must take into account possible complications in either the conscious or comatose patient.

b. Prophylaxis, diagnosis, and treatment of acute respiratory problems involving familiarity with respirator physiology, respirators themselves,

blood-gases, anaesthesia, and the relationships between respiration and fluid balance.

c. Water and electrolytes, blood-volume, and the management of cardiovascular and renal dysfunction.

d. Metabolism and the endocrine system, including the problems of intravenous feeding.

e. Management of infection and prophylaxis against infection, whether of primary origin or the result of surgery or treatment.

f. General nursing care, including the effects on staff of serious and fatal accidents.

g. Up-to-date monitoring methods to control the treatment and progress of the injured patient.

h. The provision of full-time staff to provide immediate clinical assessment and all forms of treatment.

i. Ethical and medico-legal problems involving consent for operative procedures and the selec- tion of patients for treatment in order of severity.

j. Provision of a centre for clinical research in the physiology and pathology of trauma to stimulate an enquiring attitude and co-operation between the different disciplines involved.

Though treatment of injuries to the locomotor system is the main responsibility of the accident surgeon, treatment may also be needed for injuries to one or more of the body cavities.

For about 100 years the right methods of treatment for skeletal injuries have been hotly contested between the advocates of conservative techniques and those who have upheld surgical management. Some surgeons became dis- satisfied with the result of conservative methods and were able to show that operative manage- ment which could allow early pain-free move- ment often improved the final result. As soon as such methods became popular on a wider scale, however, serious infections and soft tissue injuries were produced, leading to a swing back towards conservative management.

The brothers Lambotte were the outstanding pioneers in evolving a properly planned method of internal fixation, and their techniques were

Accident Services Today 103

published at the turn of the century. In Ger- many it was Fritz KGnig who at an early stage stressed the importance of rigidity. Sir Arbuthnot Lane and Hey Groves in England, Scudder, Smith Petersen and Eggers in America, and Putti in Italy were the men who recognized the advan- tages of rigid fixation. Danis, who based his work on that of the brothers Lambotte, was the first to develop a technically uniform instru- mentation, and was sometimes reproached for being a mechanic rather than a surgeon. He, in fact, aimed to be a biomechanic, in that he tried to make every operation a well planned and well executed experiment. Kompecher and Pauwell as well as Eggers are concerned with applied biomechanics, as are the Swiss group for the study of internal fixation (AO). It is now gener- ally recognized that biomechanics cannot be separated into dead mechanics and living bios, but that both are closely connected, in that a study of the mechanical set-up can allow fore- casts to be made about the future living reaction.

In 1940,Kiintscher took a step forward develop- ing internal fixation without the use of plates or screws. He had noted the earlier work of men such as Hey Groves who had used solid medullary nails as internal stabilizers. Everyone at the time who knew that the bony cortex depended on the medullary circulation for two-thirds of its blood-supply felt that medullary nailing must be theoretically and ‘ biologically ’ impossible. Nature has proved the contrary, as can be shown with the help of modern intravital staining methods.

Today internal fixation is being applied on a very large scale and has produced many satis- factory results. Early pain-free movement has shown that a fracture need not necessarily be followed by ‘ fracture disease ‘. The multiply- injured patient has probably derived the greatest benefit from internal fixation, as the neutraliza- tional factor greatly facilitates general nursing and intensive care.

An appropriate organization is vital in accident surgery and here I must stress the important pioneer work of Lorenz BGhler. He had of necessity to establish independent accident hospitals, though he would have preferred to work out his ideas in already established medical centres, but this was not possible at the time.

Three types of hospitals are needed in planning an accident service :-

1. The district hospital. 2. The central hospital. 3. The medical centre. The district hospital undertakes more than

50 per cent of everyday surgical work, of which more than half is accident surgery. Here the presence of a consultant is needed almost all the time and little scope is given for the future development of his assistant. The latest Swiss plan envisaged the life appointment of two surgeons as chiefs in such hospitals. One of these surgeons is expected to have his main interests in visceral surgery while the other should be primarily involved in orthopaedic and accident surgery. As each surgeon must take his turn on duty, a suitably broad training is needed for both. It is quite possible, with a thorough surgical education and continuous further train- ing, for a general surgeon to be satisfactory in the management both of abdominal injuries and of fractures. This should in no way interfere with their consultation with other specialists to help in the solution of difficult problems.

The central hospital usually has a team of at least three specialists-the general surgeon, the accident surgeon, and often the urologist. A somewhat larger building will be needed and this should include a cold orthopaedic department and an intensive care unit. The orthopaedic surgeon should also take part in the treatment of fractures. The comprehensive medical centre, as in university hospitals and similar institutions, has special clinics for different disciplines which should not be independent of each other, but should be closely co-ordinated. In the larger type of hospital, patients with multiple injuries should be under the care of a group of specialists co-ordinated by a general surgeon who is familiar with all the problems of intensive medicine.

It is important to design a proper pattern of education for those involved in an accident service. A distinction must be made between the actual service in accident surgery and the educa- tional programme required to establish this. A training exclusively in accidents will leave in- adequacies in other fields, especially in the management of injuries in the body cavities and in cold orthopaedics. Accident surgery is therefore rather like the mule, which is a favour- ite animal in Switzerland; it does very useful work but is incapable of propagation. Accident surgery cannot and should not by itself train its recruits. Ideally, intensive medicine and accident surgery should only comprise a third of the training time of our future specialists, while other specialists receive two-thirds of their training in their own field and one-third in general surgery. The general surgeon for his part spends train- ing periods of about six months in different

104 Injury: the British Journal of Accident Surgery Vol. ~/NO. 2

specialties. Accident surgery should finally pro- vide a common point of interest for the general surgeon, theaccident surgeon, and the orthopaedic surgeon, rather than be a bone of contention between all three.

In all training centres it is important to stress the broad activities that will occupy future general surgeons. A serious warning should be given to all future surgeons that they should think twice before they follow the possibly more modest but much easier course of narrow specialization.

I am firmly convinced that independent departments and clinics for accident surgery are misconceptions. Many such departments have nevertheless been set up and become isolated. They may be supervised by general surgeons, accident surgeons who have only had training in trauma, or by orthopaedic surgeons. General and trauma surgeons should always remember their limitations in the field of cold orthopaedics and orthopaedic surgeons should for their part be aware of their educational gaps in general surgery. They should always remember that the patient needs close co-operation between them.

THE ACCIDENT SERVICES IN BASLE The Surgical Department of the University of Basle admits ‘ routine accident cases ’ from the city area and its surroundings, which has in all a population of about 300,000. In addition it receives the more severe accidents from a population of some 600,000 people, taking in part of Southern Germany and the larger area of Basle.

The accident service is part of the surgical department and is a common responsibility between general surgery and orthopaedic surgery.

The Biirgerspital, Basle, was completed in 1947 but is still being modified at a cost of &37 million. At present, orthopaedic surgery and general surgery are located in different hospitals, though they belong to the same department. Fractures are treated within the general surgical department but the orthopaedic department is responsible for about half the fractures. The results of treatment are discussed at weekly rounds between the two divisions of the depart- ment of surgery.

High-quality radiography is available all the time, but there is some difficulty in staffing. Blood transfusion and laboratory services are available 24 hours a day, 7 days of the week.

There is never any difficulty in operating on real emergency cases but there is not always enough staff on duty to deal with semi-

emergencies like the internal fixation of fractures where there are no soft-tissue injuries that would make them a first degree emergency.

The facilities for dealing with the diagnosis and treatment of minor cases are quite satis- factory because there is a large out-patient department that is fully staffed and equipped.

Resuscitation is provided for in a large room where oxygen, suction, and anaesthesia are avail- able at all times. In general, radiology and all other emergency diagnostic procedures can be carried out within the emergency department.

The emergency department deals with medical as well as surgical emergencies, but paediatric cases are taken to the children’s hospital.

There is good collaboration between the departments of medicine and surgery. The department of surgery, in addition to general surgery, includes neurosurgery, cardiothoracic surgery, plastic and maxillofacial surgery, vascu- lar surgery, urology, and orthopaedics, and on the whole collaboration is close and straight- forward. The medical department, being situ- ated in the same building, is easily available for consultation, and surgical opinions are equally available for the medical department.

There is no separate casualty staff, but rather a casualty service with a rotation of those who are being trained in general surgery, orthopaedic surgery, and trauma.

The department of surgery as a whole is in control of the complete accident and emergency service.

There are 20 full-time members of staff in the department of surgery, including all the special- ties. In addition there are 15 senior residents and 50 residents. There is no difficulty in attracting enough doctors to maintain a 24-hour service every day of the week, with one or two teams available to operate at any time.

The intensive care department can admit any accident case, which will be seen by a member of its staff shortly after arrival if there is any likeli- hood that intensive care will be needed, and prophylactic measures for shock and respiratory embarrassment can be initiated at once.

In March, 1973, a new intensive care unit, comprising 25 beds divided into 3 subunits, will be opened. This will be available to all divisions of the surgical department.

Hospital infections have not been an over- whelming problem to date, but we are fortunate in having a very efficient nursing staff. Pre- ventive measures, however, should be improved and supervision should be planned more system- atically.

Accident Services Today

The follow-up of fracture patients is standard- ized, as the Basle University Department is part of the association for the study of internal fixation (A0 or ASTF) and a special secretariat has been established for this purpose. Many patients, however, return to their own doctor and may only be followed-up by obtaining radio- graphs and progress reports from their family doctor.

There is a rehabilitation unit, but only a minority of patients are referred to it. It is under the supervision of the consultant in charge of hand surgery.

Medical social workers do not yet play a major part in the hospital care of the patients as there is only one such social worker for the 300 beds in the surgical department. There is an aware- ness, however, of the need to pay more attention to this aspect.

The shortage of nurses is of great concern to us and we foresee increasing difficulties here. It is felt that for all ‘ average patients ’ perfection- ism in nursing care will have to be considerably reduced.

The autopsy rate at our institution is more than 95 per cent. There are conferences held together with pathologists and there is one regular weekly conference where all complications are discussed (the so-called ‘ complication conference ‘),

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In the region of Basle and its surroundings there are a number of small hospitals which vary widely in their facilities for emergency patients. They usually take very good care of individual fractures, but will refer patients with multiple injuries, who have any severe respiratory or circulatory problem, to our centre.

There is a first-aid cardiac team which can go out into the city on request with resuscitation equipment, and for a major catastrophe we have an organization that will provide a team to assess the patient at the accident site. As a rule, however, no doctor leaves the hospital to accom- pany an ambulance.

There are occasional rather than systematic courses given in first aid to police and firemen. Ambulance drivers have systematic training on entry into the service. The collaboration with the ambulance service is very good.

Our main difficulty is the shortage of nurses to take care of the patient with multiple injuries. There is a tendency for nurses to seek jobs in hospitals where elective operations are usual, because the hectic work of a busy emergency department is considered to be too much of a stress by many nurses. It may therefore be that intensive care cannot be provided for severely injured elderly patients with obviously bad prognoses-a fact which may face the consultant in charge with a very difficult ethical problem.

Requests/or reprints shouldbe addressed to:-Professor Dr. M. AllgGwer, Chirurgische UniversitBtklinik, Btirgerspital, B&e, Switzerland.

Letter to the Editor

Fat embolism following prosthetic replacement of the femoral head From Mr. R. H. C. Robins

Sir, In the article on ‘ Fat Embolism following

Prosthetic Replacement of the Femoral Head ’ (INJURY, 3, 85) reference is made to Hyland and Robbins (sic) and it is stated that pulmonary fat embolism was demonstrated on histological examination of post-mortem material. It is also stated that all the cases reported in the literature referred to occurred after the insertion of a Thompson hip prosthesis and none followed total hip replacement.

replacement in an elderly patient with osteo- porosis who had developed a late ischaemic necrosis following a fracture of the femoral neck. The pathologist who carried out the autopsy found both air and fat in the pelvic veins and in the coronary vessels and considered that the former was the more important cause of death acting on a previously diseased myocardium.

REFERENCE HYLAND, J., and ROBINS, R. H. C. (1970), ’ Cardiac

arrest and bone cement ’ (Letter), Br. med. J., 4,176.

Yours faithfully, R. H. C. ROBINS,

Royal Cornwall Hospital, Truro

In the interests of accuracy I feel that these statements should be corrected. In the case of the patient reported by Dr. Hyland and myself, the

Oak Tree House, Perran-ar-worthal, Truro, Cornwall.

operation was for a McKee-Farrar total hip 14 Aug., 1972.