Five Years ATLS(R)-Courses in Switzerland

Fünf Jahre ATLS (Advanced Trauma Life Support) in der Schweiz werden analysiert, die Schwierigkeiten bei der Einführung werden aufgezeichnet und die gezogenen Lehren im Verlauf der fünf Jahre werden geschildert. Einerseits galt es die Vorgaben von ATLS International zu berücksichtigen, anderseits die Strukturen als Untergruppe der Schweizerischen Gesellschaft für Chirurgie genau zu definieren und als interdisziplinäre Gruppierung die Querverbindungen zu den anderen Fachgruppen zu respektieren. ATLS Switzerland benötigt zudem spezielle Organisationsstrukturen mit besonderer Rücksichtnahme auf die geographisch-politischen Verhältnisse der Schweiz sowie auch auf die sprachlichen Gegebenheiten. Das Interesse an ATLS war sehr gross und lange Wartelisten erforderten eine rasche Steigerung des Kursangebotes. Dies war nur durch eine Dezentralisierung der Kurse auf fünf Kursorte möglich mit relativ selbständig arbeitenden effizienten regionalen Kurszentren. Die Kursstatistik wird analysiert, es wird eine gleichmässige Verteilung auf alle Regionen der Schweiz beobachtet, die Assistenten sind bezüglich Häufigkeit an der Spitze und unter den Teilnehmern zeigen die Chirurgen eine hauchdünne Mehrheit vor den Anästhesisten. Das Ziel ATLS in sämtlichen Notfallstationen der Schweiz einzuführen ist erreicht und auch bei der Armee werden ATLS-Kurse erteilt, insbesondere zur Vorbereitung auf Auslandeinsätze.

[Experiences with endoscopic carpal tunnel release]

Between 1994 and 2000 122 open and endoscopic carpal tunnel releases were performed. 82 of them were analysed retrospectively with major interest in security and results of the endoscopic technique. 39 patients were treated with an open, 41 patients with an endoscopic carpal tunnel release (26 using the two portal technique, 17 using the single portal technique). No major irreversible complications were reported, regarding the outcome their were no significant differences. From the 39 patients with open carpal tunnel release nine had persistent complaints and one of them was reoperated because of an injury of the motoric branch of the median nerve. Eight patients out of 26 treated with the two portal technique still had complaints and one needed to be reoperated because of excessive fibrosis around the median nerve. From the 17 patients operated with the single portal technique five had persistent complaints but no reoperation was necessary. Our study showed similar findings regarding security and results using the three different operation methods. But there were no advantages for the endoscopic carpal tunnel release because of the more atraumatic procedure.

[Minor craniocerebral trauma]

Mild craniocerebral injury or mild traumatic brain injury (MTBI) predominates, occurring with an 80% frequency. A 1997 publication by the American Academy of Neurology clearly defines MTBI as a transient alteration of mental status, without any neurological deficit, that may or may not involve loss of consciousness or amnesia. On the Glasgow Coma Scale (GCS), mild craniocerebral injury corresponds to a score of 14 and 15. The GCS must be taken immediately. Advanced trauma life support follows primary survey methodology and ABCDE protocol. The prognosis in MTBI is significantly worse when the patient suffers from intercurrent hypotension and hypoxia. In smaller hospitals, 24-hour monitoring is imperative. Wherever computerized tomography (CT) is available, a CT examination is broadly indicated. There is no knowledge of any adverse effects on patients whose GCS worsened when the CT revealed normal findings.

[ATLS (advanced trauma life support) in Switzerland]

We analysed the ATLS courses organized in Switzerland since 1998. At the students courses the surgeons exceed the participants with a percentage of 45.7%, followed by the anaesthesiologist with 36.3%. The senior residents dominate with 49.1%, followed by the residents with 42.3%. The chief surgeons come only to a per cent of 4.1%. The statistics of the instructors show about the same pattern, the percentage of senior residents is even more impressive. The aim of ATLS is the same concept, the idea of ATLS in all emergency units throughout the whole country of Switzerland.

[Laparoscopic cholecystectomy]

In a community-hospital the problem arises how to improve the knowledge and skill of the surgeons. As mentioned, for some reasons the possibility of training outside the hospital is limited. We get closer to that problem by operating these cases together: two surgeons of two hospitals next each other. An example to describe this problem is the laparotomic cholecystectomy.

[Should Volkmann's great triangle be screwed?]

The accurate reposition of the posterior tibia ridge is a technically exacting undertaking. On the basis of 22 screwed--all done ventrally--and 11 non-screwed Volkmann's triangles which are more than a third of the lateral extension of the distal tibia joint surface can be shown that a screwing in faulty position is worse than non-screwing. Consequently it is better to omit screwing or to do the reposition visually with the corresponding access.

Zollinger-Ellison syndrome, duodenal carcinoid (gastrinoma), and hyperthyroidism

A 43 year old man is presented who suffered from the association of a toxic adenoma of the thyroid gland and a Zollinger-Ellison syndrome (ZES) due to a metastasizing duodenal gastrinoma. There were no other signs of a multiple endocrine neoplasia syndrome, type I (MEN-I). The patient presented here shows that the association of ZES and thyroid disease may also occur in patients with sporadic ZES.

Thoracoabdominal trauma in ski accidents

Higher speed in ski sports has in recent years increased the number of thoracoabdominal injuries. Our restrospective study concerns 30 patients from the region of Chur, Switzerland, injured between 1965 and 1976. The patients were all male with an average age of 26 years. Details of the injuries, operations and treatment are given and a few typical cases are demonstrated.

[Surgical treatment of intra-articular calcaneus fractures]

The instable fractures of os calcis are usually treated by conservative methods with early functional mobilization. In a few cases we think that in the Tongue Type and especially in the Joint Depression Type of Essex-Lopresti a surgical treatment may be useful to reestablish the congruence and the geometry of the joint surface.

Fracture-dislocations of the elbow

This paper presents a series of 105 cases of fracture-dislocation of the elbow joint. All these fractures differ in mechanism, age of patient and method of treatment, so problems arise in classification. Causes can be grouped together more easily than in principles of treatment. The cases are classified into 2 major groups and 10 subgroups. Single fracture types are analysed and the optimal type of treatment is studied. As with all joint fractures, adequate reconstruction is obilgatory to remove all steps in the articular cartilage, and rigid fixation is mandatory except for the radial head, where excision is indicated. The different fracture types and their relevant operations are illustrated with examples.