113 Theatre Bleep: Quality Improvement Project

Introduction

Efficient use of any theatre is essential for timely operating and maximising the use of resources. There are many reasons for inefficiency, including delays in patient transfer, and issues of communication between the ward and theatre staff. The objectives of this QIP were to establish areas for improvement in communication.

Method

A survey was distributed amongst staff with several questions subjectively rating the communication between theatres and the ward.

Results

Common reasons listed for delays mentioned included staffing (25) and communication (19), with only 18% rating communication when sending for a patient as good, and 58% of theatre staff rating communication when transporting a patient back as poor. A common response was failure of the ward to answer the telephone. A bleep was therefore introduced, which was carried by a nominated nurse on the plastic surgery ward each shift. Following the introduction of this bleep, the survey was repeated, with 71% rating communication when sending for a patient as good, and 86% of staff rating communication when transporting a patient back as either good or excellent.

Conclusions

This simple measure of a new ward bleep significantly improved communication, and we feel this measure should be implemented nationally.

112 Trans-Scaphoid Perilunate Dislocation. Two Atypical Presentations with Enucleation of The Proximal Pole

This article describes two cases of tran-scaphoid perilunate dislocation, both of which have an atypical presentation. In both cases, the proximal pole of the scaphoid was enucleated, one into the carpal tunnel, the other into the distal forearm. In addition, the capitolunate alignment was preserved, with dorsal dislocation of the entire carpus. These cases are presented for educational purposes, as these injuries are highly unstable, and require a different operative approach to a typical perilunate dislocation. In a typical Mayfield II perilunate dislocation, the lunate remains within the lunate fossa, and acts as a 'keystone' for fixation of the dislocated carpus. These cases do not fit the classic Mayfield classification. Given the lunate was also unstable, K-wires were placed through the distal radius into lunate, then from the scaphoid into the lunate.

Another learning point for all training levels is that the referring orthopaedic hospital referred one of these injuries incorrectly as a 'lunate dislocation'. This article provides an opportunity to re-cap the Mayfield classification, and clarify the distinction between lunate and perilunate dislocation. In all cases, stringent monitoring for any carpal tunnel syndrome is required, and urgent decompression should be performed if there is any concern.

Discrepancy in clinical outcomes of patients with gunshot wounds in car hijacking: a South African experience

INTRODUCTION

Discrepancy in outcomes between urban and rural trauma patients is well known. We reviewed our institutional experience with the management of gunshot wounds (GSWs) in the specific setting of car hijacking and focused on clinical outcome between rural and urban patients.

METHODS

A retrospective review was conducted at a major trauma centre in South Africa over an 8-year period for all patients who presented with any form of GSWs in car hijacking settings. Specific clinical outcomes were compared between rural and urban patients.

RESULTS

A total of 101 patients were included (74% male, mean age 34 years). Fifty-five per cent were injured in rural areas and the remaining 45% (45/101) were in the urban district. Mean time from injury to arrival at our trauma centre was 11 hours for rural and 4 hours for urban patients (p < 0.001). Seventy-six per cent (76/101) sustained GSWs to multiple body regions. Sixty-three of the 101 (62%) patients required one or more operative interventions. In individual logistic regressions adjusted for sex and number of regions injured, rural patients were 9 (95% CI: 1.9-44.4) and 7 (95% CI: 2.1-24.5) times more likely than urban patients to have morbidities or required admissions to intensive care respectively. The risk of death in rural patients was 36 (95% CI: 4.5-284.6) times higher than that of urban patients.

CONCLUSION

Patients who sustained GSWs in carjacking incidents that occurred in rural areas are associated with significantly greater morbidity and mortality compared with their urban counterparts. Delay to definitive care is likely to be the significant contributory factor, and improvement in prehospital emergency medical service is likely to be beneficial in improving patient outcome.

The spectrum of animal related injuries managed at a major trauma centre in South Africa

BACKGROUND

Humans come into contact and interact with an array of animals in a number of areas and environments. We set out to review our experience with animal-related injuries in Pietermaritzburg, KwaZulu-Natal, South Africa.

METHOD

All patients who sustained an injury secondary to an interaction with an animal in the period December 2012-December 2017 were identified from the Hybrid Electronic Medical Registry (HEMR).

RESULTS

There were 104 patients in the study sample. The mean age of patients in the study was 32.8 years, with a range from 1 to 76 years old. 75% (n = 78) were male and 25% (n = 26) female. Out of the 104 animal-related injuries, 67 were blunt trauma, 39 penetrating trauma and 3 a combination of blunt and penetrating trauma. The species causing trauma included dogs (53), horses (29), cows (18), buffalo (1), warthog (1), impala (1) and a single goat (1). The median time from injury to hospitalisation was 46.62 hours (range from 0 to 504 hours). Injuries occurred to the head (n = 32), face (n = 9), neck (n = 32), abdomen (n = 22), urogenital system (n = 6), upper limb (n = 39) and lower limb (n = 39). The Injury Severity Score (ISS) mean for the patients was 8.16, the range 1-4, the median 9 and the standard deviation 6.88. In 49 patients the treatment was non-operative. In the remaining 55 patients, a total of 68 operative procedures were required. Operations included wound debridement/surgical washout (n = 38), laparotomy (n = 9), arterial repair/ligation (n = 8), skin graft (n = 4), craniotomy (n = 5), fasciotomy (n = 2), amputation (n = 1), and placement of an ICP monitor (n = 1). 49 of these operations were for patients with dog bite injuries. The mean hospital stay was 0.13 days with a range of 0-4 days. Four patients were admitted to the Intensive Care Unit (ICU) and two patients died.

CONCLUSION

Human interactions with animals may result in injuries which require surgical treatment. The most common animal injury is a dog bite but in the case of the larger domestic farm animals, blunt force type injuries and goring can result in significant injuries which require complex surgical interventions.

The management of penetrating neck injury

Penetrating neck injuries are serious as there is a high concentration of vital structures in close proximity to each other in a compressed anatomical area. Penetrating neck injuries can be immediately life threatening due to massive bleeding from vascular structures or due to airway compromise. Injury to the digestive tract in the neck may also result in delayed and potentially life-threatening conditions. The majority (79%) of penetrating neck injuries can be managed conservatively. The clinician caring for such a patient requires a structured and comprehensive approach to managing these injuries. This article will provide a general overview of penetrating neck injuries, including resuscitation, epidemiology, surgical management and the use of appropriate imaging.

The correlation between ATLS and junior doctors' anatomical knowledge of central venous catheter insertion at a major trauma centre in South Africa

OBJECTIVE

To review the ability of junior doctors (JDs) in identifying the correct anatomical site for central venous catheterization (CVC) and whether prior Advanced Trauma Life Support (ATLS) training influences this.

DESIGN

We performed a prospective, observational study using a structured survey and asked a group of JDs (postgraduate year 1 [PGY1] or year 2 [PGY2]) to indicate on a photograph the exact site for CVC insertion via the internal jugular (IJV) and the subclavian (SCV) approach. This study was conducted in a large metropolitan university hospital in South Africa.

RESULTS

A total of 139 JDs were included. Forty-four per cent (61/139) were males and the mean age was 25 years. There were 90 PGY1s (65%) and 49 PGY2s (35%). Overall, 32% (45/139) were able to identify the correct insertion site for the IJV approach and 60% (84/139) for the SCV approach. Of the 90 PGY1s, 34% (31/90) correctly identified the insertion site for the IJV approach and 59% (53/90) for the SCV approach. Of the 49 PGY2s, 29% (14/49) correctly identified the insertion site for the IJV approach and 63% (31/49) for the SCV approach. No significant difference between PGY1 and 2 were identified. Those with ATLS provider training were significantly more likely to identify the correct site for the IJV approaches [OR=4.3, p=0.001]. This was marginally statistically significant (i.e. p>0.05 but <0.1) for the SCV approach.

CONCLUSIONS

The majority of JDs do not have sufficient anatomical knowledge to identify the correct insertion site CVCs. Those who had undergone ATLS training were more likely to be able to identify the correct insertion site.

The effect of a concomitant renal injury on the outcome of colonic trauma

BACKGROUND

The management of colon injuries has steadily evolved over the course of the last half century. So too has the management of renal trauma. It is not clear from the literature as to whether concomitant colon and renal injuries carry increased risk of morbidity and mortality, and whether this combination of injuries necessitates a specifically tailored management approach.

METHODS

A retrospective review was carried out for the period January 2012 to December 2016. All patients over the age of 18 years who were subjected to laparotomy for penetrating trauma (gunshot wounds or stab wounds) and who sustained an intra-operatively proven colonic injury were included in this study. Operative management and outcomes were investigated. A direct comparison was made between patients with a combined colonic and renal injury and those with only a colonic injury.

RESULTS

Over the five-year period a total of 268 patients sustained a colonic injury. The 239 patients with a colonic injury (Group A) were compared to the 29 patients with a combined colonic and renal injury (Group B). Regarding the management of the colonic injuries, there were no differences in the rates of primary repair, anastomosis, exteriorization, or damage control surgery between groups A and B. As for the management of the renal injury, 14 were not explored at laparotomy; in 12 a nephrectomy was performed and in 3 the renal injury was repaired. The nephrectomy cohort were more likely to have undergone damage control surgery, to be admitted to ICU, to receive a colostomy, and had higher mortality. While there was no difference in the need for damage control surgery or mortality between groups, Group B had a significantly greater need for ICU admission. Morbidity was similar between the two groups - in particular, there was no difference in the rates of either gastro-intestinal complications or acute kidney injury between the two groups.

CONCLUSION

In patients with combined colon and renal injuries, it seems reasonable to treat each organ on its own merit, without the expectation of increased morbidity or mortality. In the non-damage control setting, most colonic injuries may be safely repaired, and a peri-renal haematoma that is not expanding or actively bleeding may be safely left alone.

The eye within the framework of human senescence: biological decline and morbidity

An introduction to basic risk theory is applied to an analysis which is used to calculate risks for mortality, age-related maculopathy, and nuclear cataract. A number of ad hoc assumptions are introduced, and the predicted results compared with results culled from the literature. The results for nuclear cataract indicate that the loss of life expectancy associated with this condition may exceed 3 years. Finally, the theory is applied to an estimate of general blindness.

Why does the human visual system age in the way it does?

The tentative observation that the decrease of lenticular glutathione in man and in cattle may be under genetic control is extended to other biological functions which show a systematic reduction with age. Ocular and visual parameters are shown to decline consistently with the view that the human eye has evolved in keeping with other biological functions sustaining a life-span of approximately 120 years. Analysis of the data suggests that presbyopia represents an outlier in the distribution of ocular attributes, and should not be used as a biomarker for ageing.

Human sensory functions and longevity

Age-related variations of human sensory properties have been expressed in a manner which permits them to be validly compared with other biological functions presented on a similar basis. They are found to be representative of much larger data-base, and it is tentatively suggested that they may have evolved in support of a life-span of approximately 120 years. Some theoretical arguments are advanced to explain this.

On the invention of the ophthalmoscope

The author offers an English translation of three passages of Purkinje's Commentatio de examine physiologico organi visus (1823). He shows that Purkinje made three inventions: (1) by using a transparent mirror, (2) by anticipating Maxwellian illumination, and (3) by providing the first recorded ophthalmic examination of animal and human eyes.

Is the season of birth a risk factor in glaucoma?

Several lines of research suggest that some systemic diseases, often associated with age-related conditions, may present with enhanced prevalences owing to very early influences on human development. This paper describes an analysis of 1264 adult Caucasian patients presenting either with primary open angle or narrow angle/angle closure glaucoma on the one hand, or with age-related cataract on the other. In addition, data on cataracts and primary open angle glaucoma on 254 patients of Caribbean origin and 190 of south east Asian origin were also examined. Patients were classified with respect to sex and season of birth. These variables can play a statistically significant role in the prevalence of glaucoma, which raises the possibility that environmental influences may be involved.

The Oqual: a new device for measuring the optical quality of the anterior segment of the human eye

An attachment to (Haag-Streit and Topcon) slit-lamps is described. This permits projection of a patterned target into the eye and the visual or photographic analysis of the details of the image reflected from the posterior surface of the crystalline lens. A numerical assessment can then be made of the optical quality of the crystalline lens as a whole, although scanning it is also possible. The attachment has also been used successfully for the objective assessment of the patient's post-operative visual acuity following kerato-refractive procedures.

Presbyopia toward the end of the 20th century

Recent advances in our understanding of the anatomy and physiology of accommodation have contributed to current concepts of the possible constituent factors in presbyopia, largely supplanting the long-held belief that presbyopia is due to sclerosis of the crystalline lens. In this review, the author examines epidemiologic, basic scientific, and clinical evidence for a multifactorial decrease in accommodative amplitude with age. Methods of measurement, oculomotor effects of presbyopia, and approaches to correcting it are also considered.

A note on a possible relation between refraction and a disposition for senile nuclear cataract

A study was made of records of patients who have had at least 1 senile cataract removed and for whom refraction records were available. The risk of a cataract occurring was determined as a function of precataractous refraction. Emmetropia was found to provide a sharp borderline between the low risk (about 1:1000) of hypermetropes and an increasing risk (about 1:100) for moderate myopes for patients in their early 60s.