Professional Documents
Culture Documents
A Introduction
A Great wars
A Future times
Section II - Epidemiology
A General principles
A Investigating trauma
A Meta-analysis
A Prevention
Section I - Conflict and glory-the human saga (a philosophical aside)
A Introduction
The Human Saga is one of conflict and occasional glory1. It seems the more we know
about this world the more meaningless it appears2,3,4. There is conflict with the
environment (fires, floods5, the workplace, pestilence, crocodiles (Fig. 1.1), beasts with
hoofs and in motor vehicles6 (Fig. 1.2), foreboding waters and lands, rock climbing,
rowing and marlin fishing) with others (wars, battles, fights, sport) and with oneself
(intellectual challenges, self doubt and loss of confidence).7,8 In major conflict, War, the
victor (and so the major player and writer of history) is the one who inflicts the most
injuries and recovers fastest from injury received. 9,10 Many of our cultural and artistic
1
Cuchulain, the legendary Celtic warrior and son of the Irish god Lugh, was feared in life and certain
death. King Conor gave him his own chariot and spears. In his last battle when mortally wounded he tied
himself to a tree so as to remain upright and to continue to strike fear into the heart of the enemy only
prepared to approach after a raven rested on his slumped shoulder. His stature stands in the window of the
Post Office, O'Connel Street, Dublin.
2
George Bernard Shaw lampooned our obsession with guns and munitions in the character of Andrew
Undershaft, millionaire arms dealer, in his play, Major Barbara. He saw in guns and gunpowder the power
to change society. “Well, scrap it….That is what is wrong with the world at present. It scraps its obsolete
steam engines….but it won’t scrap its old prejudices…moralities…religions..political constitutions.. If your
old religions broke down yesterday.. get a newer and better one for tomorrow.”
3
Dennis Sciama has said "The universe in fact is a botched job, but I suppose we shall have to make the
best of it..." W T Sullivan III The Clash of the Cosmologies Book review SCIENCE 1997 275 p1275-6
4
The essential theme of this book. The Blind Watchmaker: Why Evidence of Evolution Reveals Universe
without Design.1996 Richard Dawkins WW Norton & Co
5
Too much water (floods) in Southern China in August,1998, have affected over 200 million people whilst
too little (drought) in Karachi have thrown the city into chaos.
6
CJL Murray AD Lopez 1996 Evidence-Based Health Policy-Lessons from the global Burden of Disease
Study Science 274 740-43
7
Man has a primitive biological need to hunt, fight and to use tools from - E Sherry 1998 Chap 1 p. 8
Oxford Handbook of Sports Medicine OUP Oxford
8
“…it is a lack of confidence, more than anything else, that kills a civilization. We can destroy ourselves by
cynicism and disllusion, just as effectively as by bombs.” Kenneth Clark.Civilisation.1969 p347 BBC
Books, London.
9
“Unless we insist on denying it, our future, like that of the last Easter Islanders, may belong to the men
with bloodied hands”. John Keegan 1993 A History of War p392 Hutchinson London
10
“…Mates riddled to dog meat wholesale.
Men screaming like stallions.
Blood and shit blowing out of them in front”
from Les Murray 1998 Fredy Neptune p31 lns 17-19 Griffin Press Potts Point
endeavours are centred around these events.11 We place great value on the sacrifice
required and have celebrated it in the psalms of the Old testament and in the Catholic
Mass.12 The great German Warrior and Writer, Ernst Junger celebrated war in his work as
"our dream of greatness, power and glory... there is no lovelier death in the world"13.
Any great civilization (and at this time it is the American) depends upon a strong
military14 (as well as an emphasis on the individual and democracy). Such behaviour does
not change with age or with the Ages15. We seem to keep forgetting that altruism pays
(biologically and morally)16 although it has been said that pride and hatred not only
invigorate the soul (while love and humility enfeeble it, Hume), but may well act as the
engines of scientific progress.17 Hence the critical role of the trauma /military surgeon(the
11
Picasso’s Guernica depicts the horror of the Nazi bombing of Spain during the Spanish Civil War
12
Igor Stravinsky’s work, Symphony of the Psalms, described as “one of the most extraordinary
accomplishments in western music of this century in its suspension of time in static adoration and incantory
contemplation” gives the impression of being inspired by a harsh, strong feeling that has grown out of the
anguish of mankind, punctuated by occasional lighting falshes revealing the countenance of Jehovah.
Robert Siobham:Stravinsky,Paris,1959
13
Ernst Junger 1929 The Storm of Steel Charto and Windus/Constable and Cpy Ltd London p1
14
In the US, the Military Effort, or Department of Defence, drives much of the scientific and academic
basic research WmA Wulf Balancing the Research Portfolio Editorial Science 1998 281 p1803
15
“Men never grow up. Male maturity is a myth. We are just a bunch of no-good, grossly incompetent
human beings who throughout history have been pretending to evolve from gangling adolescence into hard-
nosed “men”….men are obsessive, sexually insecure, blubbering egomaniacs, and most of the stuff about
masculinity that men have been peddling for centuries has been sheer nonsense…Now, with a clear
conscience, you can invite your mates around, crack a slab of beer, sit down and watch the footie, fart and
belch, go and pee off the back verandah and spend hours telling really bad jokes about women with big jugs
and recounting fantasies of breath-taking sexual prowess… ”Bruce Elder. Men Behaving Sadly. Sydney
Morning Herald Newspaper. p 7s Aug 8,1998.
16
Reciprocal altruism (including to strangers) has been mathematically modeled to show that it makes
evolutionary sense. MA Nowak K Sigmund 1998 Evolution of indirect reciprocity by image scoring Nature
393 573-577
17
W Gratzer Anyone for tenets.?1998 Nature 394 843-4
fixer of their injuries and ambitions)in determining the final outcome.1819 For this reason,
The spoils of sort victory are land, gold and (unlimited) reproductive rights
(sex)21; (whose role is it protect these spoils?22). A consideration of Great Works, Great
The great medical writings of the past have, as of necessity, been about injury.
Great, as they have stood the test of time by elevating generations of physicians to feats
of clinical judgment, treatment and insight. Such works represent the clinical experience
and wisdom of their authors gained from huge clinical exposure and the determination to
record it (John Hunter, perhaps the greatest surgeon of all time, had great military
experience, monumental scientific insight but was a lousy writer and speaker with a
terrible temper and no time for manners-the latter cost him his life from a myocardial
infarction after an argument and the former almost his reputation after his death. Jeremy
Foote wrote his biography in which he all but destroyed Hunter’s reputation for nearly 50
years).
18
“Wounding and being wounded are the dark premises of healing: it is they that make the medical
profession possible, and indeed a necessity for human experience. For this existence may be conceived as
that of a wounding and vulnerable being who can also heal”. C Kerenyi 1960 Archetypical Images of the
Physicians’s Existence. Thames and Hudson. London
19
A piece of Greek pottery from the second century BC a statement written by two brothers who denied
beating up a third brother by saying “the wound(trauma)that you have we ain’t done it…”. John H Davis
1996 Chap 1 in TRAUMA 3rd Ed Eds DV Feliciano, EE Moore, KL Mattox. Appleton & Lange, Stamford,
Connecticut
20
Napoleon bequeathed 100,000 francs to his military surgeon, Dominque Jean Larrey and stated “He is the
most virtuous man I have ever known”.
21
Biologically, youth and fertility is favoured in females but “testosterone-charged” dominance in males.
Increased testosterone levels increases infidelity, violence and divorce. A Booth J Dabbs 1993 Testosterone
and men’s marriages. Social Forces 72 463-477
22
Feminization is favoured…producing a partner who is more honest,cooperative and a better father.DI
Perret et al Effects of sexual dimorphism on facial characteristics.Nature 1998 394 884-887
A Great works and great surgeons
B Ancient times
The Edwin Smith Papyrus, written between 3000 and 1600BC,describes 48 cases of
trauma from the head to the foot.23Probably the work of the great Imhotep: physician,
architect, God and chief minister to King Zoser c. 2800BC. The principles so enshrined
The Vedas, the Sanskrit sacred books were written 3500-1000BC in Ancient India.
The oldest, Rig Veda, considered the early physicians to be divine, capable of curing
The Epic Era (1000-600BC) with surgeons at work on the battlefield produced the
great work, the Ayurveda Susruta, the great Indian surgical sage from around 800BC,
Hua T’o was the most famous Chinese surgeon (born around 190AD) who was
worshipped in temples as the god of surgery. Famous texts include Nei Ching (Canon of
23
John H Davis 1996 Chap 1 in TRAUMA 3rd Ed Eds DV Feliciano, EE Moore,KL Mattox. Appleton &
Lange, Stamford, Connecticut
24
In 1862 tomb robbers at Thebes found a papyrus which they sold to Edwin Smith, an American
Egyptologist. It is the oldest Afro-Asian surgical treatise with careful clinical observations of injuries and
treatment. It is not the original but a 1,000 year old copy. It can be viewed at the New York Academy of
Medicine. Injuries are classified:(1) Favorable prognosis, “an ailment which I will treat”;(2)May go either
way, “an ailment with which I well contend”;(3)A hopeless case, Spritzfall, “an ailment not to be treated”.
Case 3 was a compound skull fracture, to be treated; Case 5 a depressed fracture, to be left; Case 8 a
hemiplegia; Case 31 is an excellent description of quadriplegia. From D LeVay 1990 Chap One The
History of Orthopaedics An invaluable source of information for this chapter. The Parthenon Publishing
Group New Jersey, USA
25
It deals with the scope and requirements of good surgical technique-the surgeon must be clean, nails
short, well-mannered, and work in a clean OR which is also fumigated. The surgeon must use inspection,
palpation, percussion and auscultation.
Chou Kung’s Medicine of Wounds (1200BC ) and one on Fractures and Wounds from the
In Japan, the first known surgical monograph was Chi-so-ki by Fukuyoshi (Showa
wrote the Keiteki-Shu with chapters on diseases of bone, wounds and the elderly. Later
works were translations of European texts until the Yoka Hiroku (Theory and Practice of
Medicine).
Hippocrates (460BC-370BC) said that War was the only proper training for a
surgeon. He came from the tradition of the natural philosophers-Thales, Pythagoras and
dislocations) from 430BC to 330BC. He ran a private practice (worked for gain) and
and social standing for the physician (he was scathing about the adventurous and
orthopaedic practice for over 2,000 years. Until recently, generations of graduating
achievements spread to Asia, Alexandria and Rome, saw the work and writings of Celsus
(25BC-50AD) He was an encyclodaedist not a physician and wrote about the cardinal
signs of inflammation.
Rome produced no great science but the great Galen (129-199AD).He was
surgeon in the Pergamon arena in Asia Minor, is called ‘The Father of Sports medicine’
and was called to Rome by Marcus Aurelius where he had an enormous practice. His
writings(over 500 of which 83 medical treatises have survived) dominated the theoretic
basis of medicine for the next 1500 years. He was dogmatic, arrogant, seldom wrong,
without followers but “the most influential writer of all time” .26,27 An original thinker he
was celebrated for his careful and accurate observations. When he died, medical scientific
Paul of Aegina (625-690AD) and Apollonius were influenced by Hippocrates and worked
in Alexandria. From the era of the Byzantine Era, the Christian Church Fathers assumed
the care of crippled children and adults. Cosmo and Damien, the Patron Saints of
Physicians and Surgeons were martyred by Diocletian in AD303, and are accredited with
the first (and only) limb transplant, of a dead Moor’s limb to a patient after a cancerous
one; done of course with the help of angels29. Medicine and religion began a long
believers from their works. There are only 300 saints associated with various diseases-
26
Galen’s bust is no where to be found amongst the other Greats of Medicine on the wall in the Anatomy
Dissecting rooms of the University of Sydney. This represents the reaction to his long domination of
medical thought (teleological explanations for everything and use of the humoral theory of
phlegm/blood/yellow bile/black bile) where in the Middle Ages he was quoted verbatim. His intellectual
integrity has been resurrected on the front page of WorldOrtho, www.worthortho.com. I doubt if the
Internet will last as long or be as influential.
27
A S Lyons 1979 p251 in Medicine An Illustrated History Eds AS Lyons and RJ Petrucelli Macmillan
Melbourne
28
C Singer EA Underwood 1962 A Short History of Medicine 2nd Ed OUP
29
R Magee Saints in Surgery 1998 ANZ J Surg68 605-610
they may have been real or imaginary people, the legends of their deeds (based upon
miracles by them or at their shrines of details of their martyrdom) fact or fantasy. Other
healing saints include Blaise (throat disorders), Barbara (breast) and Erasmus (entrails).
The Great Arab Tradition of Medicine, the medicine of later Greek antiquity,
centred on the great Rhazes (850-932AD) and Avicenna (980-1036)30. The latter wrote
his Quanum of Medicine. Moses Mainmonides wrote the Medical Aphorisms in 1497.
During the Period of the Awakening (10th to 12th Centuries) was founded the great
Montpellier, Padua, the Faculty of the College de St Come in Paris. Great hospitals,
derived from the Roman valetudinaria, were established in Baghdad (the Bimaristan Al-
Azudi in 981), London (St Bartholomew’s in 1123,St Thomas’s in 1200). Much of this
change in attitude to the sick and injured (from the Roman times where hospitals31 were
only for the wounded soldier) came from Christianity with a fostered sense of
an emphasis on simple cleanliness, Guy de Chauliac (1300-68) had surgery put into the
hands of qualified surgeons rather than quacks and introduced traction for lower limb
fractures.
30
Elgood says that Avicenna was one of the greatest men the world has seen. C Elgood 1951 A Medical
History of Persia Cambridge University Press.
31
The Romans are said to have perfected trauma care and established trauma centres around the Roman
Empire, called valetudinaria, built during the 1st and 2nd centuries AD. Roman legions had a regular
medical corp.
B Renaissance (1450-1600)
Ambroise Pare (1510-1590)was the most famous surgical figure of the 16th century in
France who was said to have revolutionized the treatment of war wounds (army surgeon
under Henri 4th and surgical adviser to several French Kings; noted the cleansing action
of maggots on wounds, used windlass traction for femoral fractures and recognized cord
compression in vertebral fractures) and saw in the modern era of prostheses and brace-
making. His great encyclopaedic work, Dix Livres de la Chirugie was written in French
(not the conventional medical Latin) with a section on surgical anatomy, the use of
ligatures and tourniquet and ended the use of boiling oil or cautery for amputation
stumps. He was a humane man at a time when it was not a marked feature of military
surgeon.32 He restored the status of the barber surgeons of France after his admission to
performed over 200 amputations in one 24 hour period during the Russian campaign,
the Red Cross (to rapidly remove the wounded from the battle field, previously left there
until the day’s fighting ended), put the hospital as close to the front as possible to start
wound surgery without delay and in the period of “wound shock” when there was some
32
He wrote of the expedition against Turin in 1537 “we entered the throng in the City….some were not yet
dead; we heard them cry out under our horses’ feet………….There happened to come in an old soldier,
who asked me if there were any possible means to cure them, I told him no; he presently approached them,
and gently cut their throats without choler. Seeing this great cruelty, I told him he was a wicked man, he
answered that he prayed to God that whensoever he should be in such a case, that he might find someone
that would doe as much for him, to the end he might not miserably languish”. From The Apollogie and
Treatise of Ambroise Pare, trans. Th. Johnson 1643,ed.Keynes G, Univ Chicago Press,1952.
analgesia and a lesser chance of post-amputation wound period sepsis and wrote about
frost-bite, trench foot, scurvy, eye infections, and stomach tube feeding.33
on trauma. He emphasized keeping wounds clean, not closing all wounds and hand
washing. Hans von Gersdorff based his handbook, Das Feldbuch der Wundarzney,
published in 1517 and the first with a lot of illustrations, some in colour, on his 40 year
army experience.
The “Age of the Scientific Revolution” in the 17th Century saw the publication of William
Harvey’s De Motu Cordis (which described blood circulation), intravenous injections and
blood transfusions. The 18th century-Hales developed artificial ventilation and measured
Rutherford nitrogen in 1771 and Priestly and Scheele oxygen in 1771and Antoine-
theories.
But it was the insatiable and all-embracing intellectual enquiries of the great John
Hunter (1728-1793 )(Fig. 1.3) which was to dominate surgical thinking from the 18th
century until the present. A word about his urbane and humanist brother, William (1718-
83), the most fashionable” man-midwife” of England, who channeled his younger brother
33
Albert Lyons The Nineteenth Century p513 Chap in Medicine An Illustrated History Eds AS Lyons and
RJ Petrucelli Macmillan Melbourne
into anatomy and surgery early but fortunately was unable to temper his intellectual
determination with soothing manners (though poor manners nearly undid the great
Hunter). John Hunter collected over 65,000 (19,000 survived the bombing of London)
specimens of plants and animals (Joseph Banks brought him a platypus from Australia) to
surgeons and scientists of the day (Jenner, Astley Cooper, John Abernethy, including the
Americans of the Civil War Fame-John Morgan, founder of the first American Medical
School at the University of Pennsylvania and William Shippen) and wrote A Treatise on
the Blood, Inflammation, and Gunshot Wounds (one of the best texts on trauma).
University of Helmsted, held a vast library of 12,000 volumes and 500 instruments
Sir John Pringle (1707-82) ,Surgeon General of the British Army was the founder
of military medicine, initiated the idea of the Red Cross34, recognized the need for good
ventilation in ship hulks and military prisons and realized that jail and hospital fever were
mortality in 1874.
B Nursing care
34
In the Battle of Dettingen,1743,the French and English combatants agreed to make hospitals sanctuaries
for the wounded. This concept was ratified by the Geneva Convention of 1864.
Established by Florence Nightingale from her experiences during the Crimean War(1853-
56).She established sanitation, food services, clean water, laundry, cleaning and statistical
The Period of Colonial Expansion by the major powers (17th to 19th centuries) saw the
need for surgical and trauma care as far away as Australia. There were 9 medical men on
the First(British) Fleet which set sail on 13 May,1788, to Australia. Remarkably only one
of 121 marines and 24 of 775 convicts died on the way out to establish Australia.
medical student for “treason-felony”, contributed hugely to the medical and civic
development of the Colony. William Balmain, Principal Surgeon of the Colony from
dispersed population, long distances, extremes of hot and cold and a hostile
environment36.
anaesthesia 1847 by WTG Morton and antiseptic surgery in 1867 with the work of
35
N Dan Chap One The Medical Men of the First Fleet, Chap One in: Australia’s Quest for Colonial Health
1983 J Pearn C O’Carrigan Eds The Univ Printery Univ Queensland
36
J Pearn 1998 A history of first aid in Australia: the evolution of prehospital care MJA168 p38-41
B Modern times
The 20th Century with major conflict of the World Wars necessitated the refinement of
MASH units in Korean War, Da Nang lung in Vietnam), electronic monitoring of patients
and refined anaesthetic services. Governments saw the virtue and likely return from huge
investments in basic scientific and medical research (National Institutes of Health in the
USA).
A Great wars
Early weapons were: the hand held as a fist (Bronowsky saw the development of the hand
as the focus of evolution and civilization), clubs, stones, slingshot, bow and arrow (4000-
The need for trauma services parallels the development of weapons of mass
destruction. Surgery was equated with the treatment of war wounds. Gunpowder was
marked by the first use of a cannon at the Battle of Crecy in 1346.Treatment was often
medical underclass).
services provided37. Two percent of the US population (of 3M) perished in the conflict
(more died from disease than injury; the Union Army lost 110,070 (plus 249,458 from
disease); the Confederates 94,000 (plus 150,000 from disease)38. The previous lessons of
A Pare of 1545 were forgotten (generals avoided having medical supply wagons), the
flying ambulance of Larrey was ignored at the outbreak, as were the nursing standards
established by Florence Nightingale (Clara Barton, recruited nurses for the Medical
Corps; later founded the American Red Cross), sterile techniques suggested by Oliver
Wendell Holmes were not applied, secondary haemorrhage from infection was common,
hospital acquired infections were rampant, 75% operations were amputations39 (15-
20%mortality for upper limb; 80% for thigh-similar figures to those reported by Pare in
the 16th century). There was some progress in the sue of antiseptics with bromine
reducing the mortality of hospital gangrene from 43.3 to 2.6% and many advances in
orthopaedic management of injuries such as: Bucks Traction, use of plaster splints, open
refinement of amputations.
J Kuz and B Bengtson, two young American Surgeons, have compiled a splendid
atlas of these injuries; paying tribute to the brave soldiers of this terrible conflict and to
37
“The American people in 1860 believed that they were the happiest and luckiest people in all the
world…” little did they realize what was about to unfold B Catton The American Heritage Short History of
the Civil War Chap I lns 1-2 American Heritage Publishing Co New York
38
GC Ward 1990 The Civil War: An Illustrated History Alfred Knopf New York
39
On Confederate physician noted “Fellow surgeons condemning compound fractures of the extremities to
the knife with as little hesitancy as if men’s limbs,like those of the salamander, were reproduced with great
certainty”. HH Cuningham 1958 Doctors in Gray Louisiana State University Press
the time when the American Nation, American Medicine and American Orthopaedic
The campaign in which John Hunter came of age. He served with the military for two
years at Belle Isle in France and in Portugal. In his subsequent book on gunshot wounds
he distinguished between primary and secondary healing, did not advocate debriding
wounds nor the removal of bullets and described the contraction of wounds.
B World War I
The conflict was characterized by the high incidence of gas gangrene from the trenches.
At the Inter-Allied Surgical Conference in Paris in 1917 was established the rule for
management of war wounds of debridement and delayed closure (unless <8 hours old).
B World War II
Saw wounds fully debrided and left open, use of whole blood transfusion at the battle
front and special surgical units (AUX), use of antibiotics, intramedullary nailing of the
After the war L Bohler (1885-1973) set in writing the standards of fracture
management.
40
JE Kuz BP Bengston 1996 Orthopaedic Injuries of the Civil War Kennesaw Mountain Press Georgia
B Korean conflict
From this arose the MASH unit (near area of conflict), helicopter evacuation over rough
terrain, vascular repair in limb injuries, use of antibiotics, and recognition of early renal
B Vietnam War
Further use of helicopter evacuation, laboratory back-up in the field and use of artificial
kidney.
It is worthwhile to look at the mortality from injury of these four conflicts to see
how trauma services have developed (Table 1.1). From 1972 R L Huckstep (1926-) (Fig
1.4) of Australia established new and innovative standards for complex fracture
management (after earlier producing a guide for the care of the patient with
poliomyelitis).
Although developed in earlier wars, the British-Argentinean Conflict saw the widespread
use of the the FST, the field surgical team, which was a highly mobile team (surgeon,
anaesthetist, resuscitation officer, four theatre technicians, blood transfusion, technician,
Illustrated the need for fast forward units to go with troops into battle. Six emergency
points from which resuscitated patients were taken to a single joint casualty-collection
The US-Iraqi Persian Golf War-the most rapid assault and seizure of an objective in
modern warfare (100 hours) with a very low loss of troops (331 deaths or 1% of Vietnam
fatalities, most noncombatant). This low mortality was due to rapid evacuation and
excellent clinical care. Contrast this with the Afghanistan Guerilla War where head, neck,
thorax and abdominal injury patients died on the battle field and the nearest hospital was
4 days away(only limb injuries got there for debridement and fixation;10.2% of
These include: the Committee on Trauma of the American College of Surgeons (ACS)-
which has advanced the standards of trauma care; American Association for the Surgery
of Trauma (AAST-established 1938); the American Trauma Society (founded 1968), the
41
MK Bhatnagar GS Smith 1989 Trauma in the Afghan guerilla war: effects of lack of access to care
Surgery 699
American Burn Association founded 1967, the American College of Emergency
A Future times
Specialized care for trauma victims will be the way of the future and the refinement of
such care will depend upon innovation, inventions and advances in medical science42.
The paper, “Injury in America”43-resulted in the establishment of the Center for Injury
It seems that, despite the collapse of the USSR, the likelihood of armed conflict
will continue from sectarian squabbles and political instability in Developing Countries;
many of whom have access to high-technology and nuclear/chemical weapons. The (US)
military will be called upon to police upheavals in Europe (Yugoslavia), Middle East
(Libya) and Africa (Rwanda). 85% of the support structure for the US Army comes from
reserve forces and it will continue to be up to the medical community to support the
An important paper in Science has highlighted the challenges ahead44. War and
road traffic (motor vehicle) accidents, the 16th and 9th leading causes of DALYs
in 1990,will rise to 8th and 3rd respectively by the year 2020. This is thought to be from
42
The World Bank has identified the widening "knowledge gap" between rich and poor nations and is
focusing on innovation and research rather than building dams and bridges. Urgent thinking required about
development Editorial Nature 1998 395 p527 ie Good science produce inventions which fuels economies.
43
Committee on Trauma Research, National Research Council, and the Institute of Medicine: Injury in
America Washington DC National Academy Press 1985.This was a landmark paper; in the same year the
US Congress approved a 3 year pilot program to implement its recommendations.
44
CJL Murray AD Lopez 1996 Evidence-Based Health Policy-Lessons from the global Burden of Disease
Study Science 274 740-43
the dramatic growth of the young adult population45 as well as the increased use of
tobacco and alcohol in the developing World (other risk factors include: malnutrition;
poor water supply, sanitation, hygiene; unsafe sex; occupation46, hypertension; physical
Whilst the challenges of the future seem daunting they are not insurmountable47.
Many of our forbears faced and overcame greater problems with significantly fewer
resources at hand.
easing life in the West) has a real chance of solving global poverty by providing life-
saving economic opportunities to countries such as Bangladesh49. Amartya Sen, the 1998
Nobel Prize winner in Economics, has said that societies should attend to the poor and
social goals (health and education) otherwise they will be condemning their poor to
famine and death (even in the midst of an economic boom) and risk social upheaval (as in
Indonesia in 1998)50. Even George Soros has echoed these sentiments and sounded the
alarm bells about the relentless and destructive drive of the global free markets in the
absence of a global society (health and education should be off-limits to the free
45
China's S-Generation, the single child generation, all 400 million under 20,are triggering a consumer
revolution (for S-Type Jags and electronics)with high expectations and a fear of failure. C Li, PA Loconto
1998 China: The Consumer Revolution J Wiley & Sons May be the start of the new S-Age?(ES-comment).
46
In Australia, more people die from workplace accidents than from road traffic accidents.
47
Managed Care-the great “ogre” shifting medical decisions from doctors to accountants and businessmen
will falter with time and a new equilibrium established. CE Koop 1998 Protecting Medicine in the 21st
century Science 281 p1952-3
48
The Internet may prove bigger than the Industrial Revolution; see www.orthosearch.com; there's also-
fractal geometry, quantum teleportation (A Watson 1997 Science 278 p1881-2),and NASA’s “Origins”
program to tackle the big questions of life (EJ Chaisson 1997 Science editorial 275 735).
49
The work of this man in creating entrepreneurial opportunities for the rural poor is remarkable and noble.
M Yunus Alleviating Poverty Through Technology 1998 SCIENCE 282 p409-10
50
The Real Causes of Famine J Sachs 1998 Viewpoint TIME Oct26,p61.The comment about social
upheaval is mine(ES)
marketers)51. And we are at the "dawning of the age of spiritual machines".This may well
be the last generation of Homo Sapiens subject to biological wear and demise52.
But that may not be enough to get 'Homo sapiens settled down and happy before
not just on expanding scientific frontiers(as one might expect from an American) but
Hippocrates, Galen, Hunter and our patients would never forgive us if we showed
anything but fortitude54, courage and enthusiasm for the opportunities and challenges
51
G Soros 1998 The Crisis of Global Capitalism: Open Society Endangered.
52
JL Casti 1999 Exit Homo sapiens,stage left Nature 397 p663-4 Homo sapien's day in the sun
as the leading intellectual force on the planet is just about over.Computers will have outperformed us
within 20 years.Super-intelligent robots "will be our heirs,sharing our goals and values".Such machines will
offer "lowly caron-based forms the best chance of immortality".
53
EO Wilson 1998 Consilience The Unity of Knowledge Vintage New York p325-6 Essential reading
for all scientists and clinicians.
54
C Gray BMJ 7159 Volume 316: Saturday 5 September 1998 http://classified.bmj.com/careerfocus/
Developing the medical mind….Unlike the gentlemen scholars of past centuries, few doctors today have
been trained in thinking or logic, philosophy or ethics, and culture is usually reserved for a sleep in front of
Channel 4. ... Most of us get by on pattern recognition, regular routines, and lists of things to do …..doctors
of all ages….are failing to make the best use of their brains…
Section II - Epidemiology55
A General principles
Epidemiology (from the Greek epidemion to visit) is the medical discipline that deals
with the occurrence, causes and prevention of disease. Its methodology, used in public
health to study outbreaks of disease and to design preventive measures, is widely applied
in trauma rather than illness or disease. Trauma is the term for bodily damage in a
clinical, emergency, surgical or combat setting; injury is used in the non clinical public
contributes much to better understanding of the incidence and causes of injuries and
allows planning of prevention programs and the proper allocation of medical resources.
be avoided (e.g. no clear hypothesis under test, poor definition of injury type,
results).
A Investigating trauma
studies define the problem in terms of incidence and prevalence. Analytical studies seek
to identify risk factors with the goal of doing something about the injury rate, or to
55
E Sherry Epidemiology of Sporting Injuries Chap Two in E Sherry SF Wilson Eds 1998 Oxford
Handbook of Sports Medicine OUP Oxford
Incidence and prevalence Incidence (rate) of injury is the number of cases per unit
time. The rate of injury is measured as the number of injuries or injured athletes (note the
type) over a specified period, and may be expressed in absolute or relative terms. The
risk of injury (the probability that an individual will be injured) is measured in the
methods (difficult) or from incidence densities. These two parameters provide the basis
Risk factors Identification of risk factors provides a means for doing something
about the sports injury problem. Both the observational and experimental approaches of
Case-control (Fig 1.5) - the injured group is compared with a non-injured group in
relation to a potential risk factor. Such studies are retrospective, easy to conduct and
commonly used, but careful matching of controls is important. The possible sources of
bias, role of sampling vagaries and confounding variables must be carefully assessed.
Cohort (Fig. 1.6) - similar design, but prospective in that groups exposed or not
exposed to a potential risk factor are recognized before injury and then followed through
time. This approach is less susceptible to information bias (see below). data collection
takes longer and the method is more expensive to implement . Variations include
56
RL Lieber 1994 Experimental design and statistical analysis. In SR Simon Rd Orthopaedic Basic Science
p 626-659.
Athlete Injury/Illness Reporting System in the USA or NEISS). In survival designs,
Cross-sectional (Fig. 1.7) - documents injuries and risk factors at one point in
time, describing prevalence and injury patterns. This approach is of limited value where
treatment.
randomized control trials (Fig. 1.8) which should be double blinded as compliance with
protocol is otherwise difficult to achieve. The study plan covers selection of patients
Appropriate study design may at first appear daunting. It is best practice to enlist
to avoid the frustration of having your work rejected on the grounds of unsound design,
shows that this would have been possible with proper planning to ensure adequate
statistical power, see below). Plan the investigation with definite objectives in view by
formulating test(s) of a working hypothesis (see discussion of null hypotheses below).
Know what questions you are asking and why they are relevant in the context of
will start the investigation. Usually injury is defined as being serious enough to need
Diagnostic tests needed for the study should be assessed for accuracy or
predictive value (ability to pick-up the condition). This depends on (1) Sensitivity,
measured as the fraction of people with the condition who are actually identified as
positives by the test and (2) Specificity, measured as the fraction of people without the
condition who are identified as negatives by the test. Predictive value should ideally be
near 100% (achieved when both sensitivity and specificity are near 100%). The kappa
coefficient estimates interobserver reliability (two or more observers using the same test
get the same result). Intraobserver error is a measure of the consistency of one observer
(the population at risk, e.g. the number of persons exposed during a specified time
period). The population time is the number of participants at risk by the time exposed to
potential injury. These units provide a basis for comparisons between studies.
Controls must be similar to the study group, using the same inclusion and
exclusion criteria (apart from injury).
be minimized. Such errors may arise from the way that subjects or controls are chosen
sources are recall bias (in case-control studies arising from retrospective recall of risk
factors); follow-up bias (in cohort studies where players leaving the study differ from
those remaining) and historical bias (where 'historical controls' in sequential periods are
study variable (e.g. risk factor) and the occurrence of injury in such a way as to obscure
the true relationship between study variable and injury. The confounder may itself be
another risk factor. Features of experimental design may help to mitigate difficulties
caused by confounding variables. For instance, in stratified trials, subjects are divided
according to one or more of the variables concerned (such as age, gender, smoker/non-
smoker) and subjects in each of these groups are then randomly allocated to control or
treatment. The effect of the grouping variable (potential confounder) is thus eliminated.
relation to the nature of the investigation before the study can be commenced. This is
especially important where treatment alternatives are planned. Where the study may
with the results, approval of the project by the appropriate community leaders may be
institution. Many journals now require evidence that such approvals were obtained before
considering the results of such studies for publication.
Pilot studies (small scale preliminary investigations) are often helpful or even
the sponsoring institution. Both will ordinarily necessitate assessment of the statistical
power (see below) of the proposed investigation. Such calculations require estimation of
the expected magnitude and variance of the differences between the groups being
compared, and hence the scale of the anticipated response to treatment. Preliminary
evaluation of possible confounding factors may also be necessary. A pilot study is often
the only way of providing this information where the proposed research breaks new
ground. Further, a pilot study may also be helpful in testing and justifying proposed
inclusion and exclusion criteria for study subjects, and in providing evidence that
proposed recruitment rates are realistic in relation to the proposed time frame of the
investigation.
Statistical power and the calculation of required sample size Does the observed
difference between two groups being compared reflect a real difference between them or
the probability (P) that a difference as large or larger than observed would arise from
random sampling effects alone. If sampling effects would account for differences of the
observed magnitude only rarely, we may judge it unlikely that chance alone accounts for
the difference and conclude that other systematic factors are involved. But just when do
we regard the differences as sufficiently likely to involve factors other than chance
sampling effects that we call them 'statistically significant'? Where we set the cut-off
between 'significant' and 'non-significant' is entirely arbitrary. We can set the significance
level, denoted as alpha, to any P-value that we consider appropriate for a particular
biomedical studies, the critical threshold value of P is generally set at 0.05, i.e. alpha =
0.05. At this threshold, if there is 1 chance in 20 or less (<5% probability) that random
sampling effects could account for a difference at least as great as that observed, we
regard the difference as significant i.e. likely to arise from systematic causes such as the
effects of treatment. Other significance levels, such as alpha = 0.02 or 0.01 may of course
Formally the use of probability in this way is based on testing the validity of the
null hypothesis (Ho) that there is no difference between the populations of which the
groups being studied represent random samples in relation to the attributes being
compared (mean, variance, proportion, survival curve). For each null hypothesis an
alternative hypothesis (H1) exists, here that the populations represented by the study
samples are in fact different. In the specific context of risk factor analysis a null
hypothesis may be phrased to state that there is no association between the dependent
Once the null hypothesis has been formulated and an appropriate statistical test
has been selected (Table 1.2), P can be calculated and statistical significance judged
Statistical errors of two kinds, known as type I and type II errors, relate to the null
hypothesis as follows:
Null hypothesis not rejected Null hypothesis rejected
True Correct Type I error
False Type II error Correct
A type I error arises if the null hypothesis is rejected (because the calculated value
of P is less than alpha) even though the null hypothesis is in fact true. A type I error is
equivalent to the mistake made if a verdict of guilty is brought in when the accused is
innocent. The probability of making a Type I error is alpha which was set by the
investigator. the lower alpha is set, the fewer the type I errors, but the higher the chance
of type II errors. A type II error arises when the null hypothesis is not rejected even
though it is false i.e. the alternative hypothesis (H1) is true. A type II error is equivalent to
the mistake made by a verdict of not guilty when the accused is in fact guilty. The
probability (beta) of making a type II error depends on the size of the difference specified
by the alternative hypothesis (H1), and this reflected a decision on the part of the
significance. Simultaneously reducing the chances of making type I and II errors means
increasing sample size. Whether this is feasible will depend on practical considerations
Statistical power and the calculation of sample size The power of a statistical test
is defined as (1- beta) where beta is the probability of making a type II error (see above).
Statistical power is the probability of finding a significant difference when the difference
between the populations sampled is delta. The larger the sample size the greater the
power of the test. Methods for calculating sample size 57 (appropriate for studies of
57
DG Altman 1991 Practical Statistics for Medical Research. London, Chapman and Hall.;
different kinds are provided in most statistical packages (see below). Remember to
include an adequate allowance for likely drop-outs during the study. Long-term studies
are particularly susceptible to drop-out losses and poor follow-up rates (few have been
intervals (CI, set to any level, but typically 95%) within which population values or
Outliers Once data is collected, occasional values may be seen to fall outside the
range of the main body of data points. These must all be accounted for and must not be
arbitrarily discarded as erroneous without investigation. Some will turn out to be due to
subject, missed exclusion criteria etc. Residual exceptions for which no explanation is
What statistical tests should be used for the analysis? This depends on the
objectives of the study and on the kind of data, whether measures of variables with
underlying Gaussian (normal) distributions, rank or score data, binomial (two outcome)
data or survival curves (Table 1.2). For large scale or complex investigations it is
the project. it may be too late to achieve the full potential of an investigation if this is
package. Amongst the more widely used professional level packages for independent
Package Company
SYSTAT Systat Inc, Evanston, IL, USA
STATISTICA StatSoft, Tulsa, OK, USA
SPSS/PC+ SPSS Inc, Chicago, IL, USA
SAS SAS Institute Inc, Cary, NC, USA
MINITAB Minitab Inc, State College, PA, USA
STATGRAPHICS Plus STSC International Ltd., Windsor, Berks, UK
Authoritative but less comprehensive (and less expensive) although adequate for many
Package Company
INSTAT and PRISM GraphPad Software Inc, San Diego, CA, USA
STATVIEW Abacus Concepts Inc
What conclusions should be drawn from the study? If the research project was
properly planned with clearly formulated objectives based on well-stated hypotheses, the
analysis will necessarily provide the basis for statistical (mathematical) findings. But
statistical significance does not carry an inference of clinical importance (an observed
effect in the real world). Some statistical findings are medically meaningless and
sometimes statistics may not detect an important relationship from a given data set
In summary:
• Estimate the necessary sample sizes; allow for drop-outs; check that
subject pool
individuals concerned
or blinding criteria)
objectives
mathematical) importance.
A Meta-analysis
a given topic58. The goal in the medical context is to combine heterogeneous pooled data
Chambers I and Altman DG 1995. Systematic Reviews. BMJ Publishing, London. Cook TD et al. 1992.
58
It offers no universal solution in the search for optimal medical treatments and
‘best practice’ and must always be subject to critical evaluation. The value of the output
must clearly depend on the generalizability, scale and sampling strategies of the input
studies 60.
facilities, cost, achievable recruitment rates and ethical considerations often limit studies
to a very small scale statistically (in contrast for instance to very large scale international
drug trials). If the best that can be achieved in relation to a given intervention is reflected
validity and the age, sex, genetic/ethnic background, nutritional status, physiology and
behaviour (drug use, exercise) of the subjects. But just as the power and potentially
unique contribution of meta-analysis comes from combining the results of multiple small
studies on a particular topic, so its greatest potential weakness is that any incorrect
conclusion reached may superficially appear scientifically robust due to the false security
provided by a base of multiple samples and apparent replication. LeLorier et al. (1997)61
suggest that conclusions from meta-analyses of drug trials may have supported
59
Cook TD et al. 1992. Meta-analysis for explanation: a Casebook. Sage, New York.
Hedges LV and Olkin I 1985. Statistical Methods for Meta-analysis. Academic Press,
Orlando.
Hunter JE and Schmidt FL 1990. Methods of Meta-analysis. Sage, New York.
60
Dickersin K Scherer R and Lefebvre C 1994. Identifying relevant studies for systematic reviews. BMJ
309:1286-1291.
61
LeLorier J et al. 1997 Discrepancies between meta-analyses and subsequent large randomized, controlled
trials. New England J Med 337:536-542.
ineffective treatment regimes in as many as about 30% of instances while also leading to
With these limitations in view, special attention needs to be given to defining the
criteria by which studies are selected for inclusion in a meta-analysis 62.A systematic
preliminary analysis and may need to be eliminated. Examination of the combined data
using randomization tests may be useful. Covariation of characters in real data sets is
expected to be much higher than in comparable randomly generated, simulated data sets
specified number of iterations with the patterns of covariation among characters seen in
attempt to measure an unknown distribution by repeated resampling from the data (taken
simulated data sets by random sampling of specified elements of the actual data matrix.
Estimates of the frequency of occurrence of particular features in more than, say, 100
repeats of this procedure can be used as indices of the level of support for that feature,
62
Chambers I and Altman DG 1995. Systematic Reviews. BMJ Publishing, London
63
Rosenberg MS Adams DC and Gurevich J 1997. MetaWin. (A computer program for meta-analysis
written for Microsoft Windows 3.1, 95, NT). Sinauer Associates, Sunderland.
akin to setting confidence limits. Jack-knifing involves repeated resampling from a
simulated data set from which selected elements are systematically omitted without
•trauma is the leading health problem in the USA with >140,000 deaths annually
(147,891in 1995) and the leading cause of years of potential life lost prior to age 65
•one third of the population sustain a non-fatal injury each year(most common cause of
64
JT Murphy Chap One Epidemiology of Trauma 1994 The Parkland Handbook Trauma Handbook M A
Lopez-Viego Ed Mosby-Year Book, St Louis, Missouri . Much of this data is from the National Centre for
Health Statistics in the USA which publishes a yearly mortality report which summarizes deaths in the
USA.
65
NCHS Vital Statistics System 1995 www.cdc.gov/ncip
•>90% survive their injury
•most highly injured group are 15-24 years with MVA causing >54 % injuries
•-falls exceed MVAs as the leading cause of nonfatal injuries (and cause 12,000
•75% homicides were firearm related, handguns (homicide is the leading cause of death
for black males aged 15-24 years; and leading cause of occupational death in New York
City and Los Angeles)66. "If current trends continue, by the year 2003 firearm deaths will
surpass motor vehicle-related deaths as the leading cause of injury and death in the US"67.
•burns cause 6,000 deaths/year (death is from inhalation of CO and toxic substances,
alcohol and cigarettes are factors in house fires), lightning causes 80 deaths/year.
However decreasing incidence with education about smoking and alcohol use in bed
to time. There are 3 peaks (immediate, half of all deaths, not possible to save, from
massive head injury/brain stem injury/major cardiovascular; early, within first few hours,
66
ML Rosenberg et al have identified biological (eg. age, gender, psychiatric illness)and sociological
factors(based on social learning theory where culprits learn from their violent peers with cultural,
structural(poverty), interactionist and economic features) to account for assaultive violence in the USA.
1991 Violence in America :A Public Health Approach OUP New York
67
MD Grossman 1998 Introduction to trauma Care Chap One in Trauma Manual Eds AB Peitzman et al
Lippincott-Raven Philadelphia
from torso trauma in these cases, introduces concept of "golden hour"; late deaths, about
20% of all, from organ failure and sepsis, influenced by inadequate early resuscitation or
care)68.
Within the UK the supervision of care of Accident & Emergency Department was the
committee indicated that from the staffing point of view, the Orthopaedic solution had
1971 the Joint Consultants Committee recommended that Accident & Emergency
Consultants give musculoskeletal trauma as their major interest (only about a dozen
surgeons out of >1,000 practice primary and secondary trauma alone). In the United
injuries each year, of which >100,000 are left with a significant disability. Only two units,
Edinburgh and Oxford, have completely separated the management of acute injuries from
elective practice. In Oxford the unit is staffed twenty-four hours per day by a resident
68
DD Trunkey 1983 The trimodal distribution of death after injury. Scientific American 249 2
69
C Oliver 1997 Trauma Column WorldOrtho www.worldortho.com
The Oxford consultants act as trauma team leaders in Accident and Emergency whilst the
B Trauma in Australia
Similar data to the USA exists in Australia for general injury and motor vehicle fatalities
(Table 1.4) with significantly fewer firearm injuries and declining road fatalities,
especially since 198970, (Table 1.5) because of random alcohol breath testing and use of
seat belts and airbags. There are significant numbers of swimming pool fatalities
involving children.
B Trauma in Europe
B Trauma in Singapore
Trauma is the leading cause of death in Singapore for those<40 years71. Over half are
from motor vehicle accidents, <3.5% from assault and no gunshot injuries (stiff legal
penalties have almost abolished private ownership of firearms in this country). Although
77.6% are unavoidable, 25% have been found to be potentially or frankly preventable72.
70
Federal Office of Road Safety,Australia http://www.dot.gov.au/ for further information, email:
forsstats@dot.gov.au.
71
PTC Iau et al 1998 Preventable Trauma Deaths in Singapore 1998 Aust NZ J Surg 68 820-25
72
Guidelines of the Trauma Research &Educational Foundation of San Diego, classified as "not
preventable", "potentially preventable" and "frankly preventable".
Even in a small island city-state 50km long with 5 government general hospitals the
There is a growing epidemic of trauma in the Developing World which has been noted by
orthopaedic surgeons working in these areas. In particular, motor vehicle accidents which
are now the third highest cause of death.73 Factors include: the large number of
pedestrians and cyclists (many living below the poverty line) involved in RTAs;
overcrowding of public transport; poor maintenance of roads; few speed restrictions; and
the under-developed medical management and treatment of such trauma. This does not
include the non-fatal trauma which occurs at home (poor vision from cataracts may be a
significant factor) and in the workplace and also from natural disasters.
Pearn, Taylor and Holian have written about the Aitape tsunami disaster which hit
struck a 33km coast line and destroyed 16 villages, 2200 died and displaced 9,000
73
WJ Cumming 1998 Newsletter WOC 76 p1-3.
74
Rescue Pearn et al.1998 Med J Aust 169,11/12 p601-10 Pearn emphasized the skills of triage, the need
for speed and prevention of secondary trauma and disease. Aims of treatment were diagnosis, debridement,
effective traction and immobilization of fractures with definitive fixation in the second week. The Red
Cross surgical principles(wound assessment, wound excision and decompression, antibiotics, IV
chloramphenicol, undisturbed dressing techniques, odour/temperature and pulse as indicators of inadequate
initial wound care, delayed primary closure with/out skin grafting at 4 to 5 days)were followed.
A Prevention
W Haddon, the first Director of the US National Highway Traffic Safety Administration,
host/vehicle/environment)75:
-prevent the creation of hazards (limit firearm sales e.g. Handgun control in Australia in
1997)
-preventing the release of a hazard (child-proof medication holders) or modify its release
-separate hazards from hosts in terms of space and time (traffic overpasses to prevent
congestion)
education campaigns with intention of altering behaviour; such as driver education about
fatigue and alcohol/drug, use of seat belts and air bags, not often successful where
compliance required e.g. putting on seat belt versus automatic triggering of airbags);
Legal regulation of Behaviour (to protect individual and others exposed such as speed
75
W Haddon 1972 A logical framework for categorizing highway safety phenomena and activity J. Trauma
12 297
restrictions, which decreases injury rate76 , use of helmets and alcohol restriction) and
/child restraints; building better and safer highways with divided highways/break away
light poles; water sprinklers in buildings). All such measures need to be subjected to cost-
benefit analysis (how much to spend, how to spend it and how to make the service
available). Haddon’s approach has been hailed as the greatest public health achievements
of the century which has reduced the US road mortality to one third of that of the 1950.
In contrast little progress has been made in reducing firearm violence in the US.
Such measures can be reduced to four steps: (1) Define the problem, (2) Identify
causes and risk factors, (3) Develop and test interventions, (4) Implement interventions
76
Kloeden CN, McLean AJ, Moore VM Ponte G 1998. Travelling speed and the risk of crash involvement.
FORS CR 172http://raru.adelaide.edu.au/speed/