Tag Archives: history

November Trauma MedEd Newsletter Released!

The November newsletter is now available! Click the link below to download. This month’s topic is “History”, and I look at the impact of articles written 20-25 years ago on your current practice.

In this issue you’ll find articles on:

  • Trauma and critical care
  • CT imaging of the aorta
  • ED intubation for head injury
  • Seatbelt injuries
  • CAVR for hypothermia
  • Early or delayed femur fracture fixation

Subscribers received the newsletter last Monday night. If you want to subscribe to get early delivery in the future (and download back issues), click here.

Click here to download newsletter.

The Robert Jones Dressing

The Robert Jones dressing is a thick, padded bandage classically applied to the thigh and leg. It is thought to reduce swelling by applying even pressure to the extremity, which in turn should promote healing. And since it is a soft dressing, as opposed to a cast, there is less chance of developing skin breakdown from direct pressure. Here’s a compression-type dressing described in 1937 using stockinette, cotton wool, and elastic cloth, although it was not attributed to Jones at that point.

Charnley provided a detailed description of the bandage in 1950, and was the first to refer to Jones.

Interestingly, Robert Jones never really referred to the dressing by name. There were references to a “pressure crepe bandage over copious wool dressing” in his operative logs, but it wasn’t until much later that his name became associated with it. Because of this, the composition of the bandage has varied greatly over time.

But who was Robert Jones? We in the States are fairly ignorant, but my UK readers are very familiar. Jones was a British surgeon who practiced through the late 1800s and past the end of World War I. He learned about fractures from his uncle, and became one of the few surgeons of the time to be interested in fracture care. Until then, orthopaedics was focused primarily on correcting deformities in children. He received his FRCS in 1889. After being appointed Surgeon-Superintendent of the Manchester Ship Canal, he established the first comprehensive accident service in the world to take care of injured workers. He founded the British Orthopaedic Society in 1894, and introduced the concept of military orthopaedic hospitals during World War I. His innovations led to significant decreases in morbidity and mortality from fractures in the war, particularly of the femur.

And does his eponymous dressing actually work? There has been little research in this area. There is one study that I have found that actually measured compartment pressures to see if the loss of edema from compression caused a noticeable pressure decrease. Here are the factoids:

  • This was a very small prospective study from 1986 of 9 patients (!) who had just undergone knee arthroplasty
  • Slit catheters were placed into the compartment 10 cm below the knee joint (but they didn’t say which compartment)
  • Thick cotton-wool from a roll was applied over the surgical dressings twice, each with a thickness of two inches. An elastic bandage was then applied snugly.
  • Much to the researchers’ surprise, compartment pressures did not fall as expected over time. They were basically constant until the dressing was removed. Then the pressures fell significantly.

Bottom line: Robert Jones’ fame is well deserved. However, his dressing (which he did not name, and may not even be what he used), did not have the pressure-reducing effect on an injured limb that surgeons thought. No studies on edema and healing have been done. It’s basically a fluffy dressing. However, that is a good thing. It keeps the leg padded, protecting the skin, and immobilized. It’s like a very well padded cast, without the risk of skin breakdown. And because of its simplicity, it will probably be used for quite some time to come.

Related posts:

References:

  • The Robert Jones bandage. JBJS 68B(5):776-779, 1986.
  • The treatment of fracture without plaster of Paris. Closed Treatment of Common Fractures, E&S Livingstone 1950, pg 28-29.
  • Handbook of Orthopaedic Surgery. CV Mosby 1937, pg 418.

Trauma 20 Years Ago: CAVR For Hypothermia

Hypothermia is the bane of major trauma resuscitation, causing mortality to skyrocket. A number of rewarming techniques have been developed over the years. These are classified as passive (the patient generates their own heat) or active (we deliver calories to them), and noninvasive vs invasive. Rewarming speed increases as we move from passive to active and from noninvasive to invasive.

Continuous arteriovenous rewarming (CAVR) is one of the invasive techniques used today. Its use in humans was first reported 20 years ago this month. Larry Gentilello at Harborview in Seattle had experimented with this technique in animals, and reported one case of use in a human who had crashed his car into icy water. After a 20 minute extrication, the patient was pulseless with fixed and dilated pupils, but he regained pulse and blood pressure at the hospital.

The initial core temperature was 31.5C. Peritoneal, bladder and gastric lavage were carried out for warming, as was delivery of warm inspired gas via the ventilator. However, after an hour the temperature had dropped to 29.5C. CAVR was initiated as a last-ditch effort using a jerry-rigged Rapid Fluid Warmer from Level 1 Technologies. The core temperature was raised to 35C after 85 minutes.

The patient did have typical complications (ARDS, acute renal failure), but survived with recovery of his renal and pulmonary function, and a normal neurologic exam. At the time, the authors were unsure whether the complications were due to the near-drowning or the rapid rewarming.

Reference: Continuous arteriovenous rewarming: report of a new technique for treating hypothermia. J Trauma 31(8):1151-1154, 1991.

Related posts:

Why Do They Call Them Rounds?

Face it. Everyone uses this term. But where did it come from? After a little digging, I think I’ve found the answer. I’m sure someone will step forward and offer another explanation, but the origins of some of our traditions grow foggy with time.

Supposedly, the term “rounds” was introduced by Sir William Osler, the famed physician, while he was at Johns Hopkins hospital in Baltimore. The original building was built in the 1880s and had a round dome. Osler and his trainees had to walk circular hallways to see their patients. I’ve not been there, but looking at the picture above, the corners of the building appear to be octagonal patient wards as well.

The term has stuck with us, and today just about every discipline from prehospital to rehab medicine use it! If anybody has another theory or correction, please let me know!

Reference: CIRCULAR HOSPITAL WARDS: PROFESSOR JOHN MARSHALL’S CONCEPT AND ITS EXPLORATION BY THE ARCHITECTURAL PROFESSION IN THE 1880s. Medical History 32:426-448, 1988.

Trauma 20 Years Ago: Trauma & Critical Care

For those of you who read the Journal of Trauma, the first issue of 2012 just arrived in the mail. It sports both a new cover design and a title change. For many years, it was just The Journal of Trauma. Then, after 20 years under the editorship of John H. Davis, the name changed to The Journal of Trauma, Injury, Infection, and Critical Care in 1995. This occurred as Basil Pruitt became the new editor. 

Now, after 17 years under Dr. Pruitt the Journal has a new editor (Gene Moore) and a new title: The Journal of Trauma and Acute Care Surgery. According to the instructions to authors, the journal continues its focus on trauma, emergency surgery and the care of critically ill patients.

These days, the relationship between trauma and surgical critical care seems self-apparent. The two truly go hand in hand, and most Level I and many Level II trauma centers in the States boast trauma surgeons who are deeply involved in and certified in surgical critical care.

But it wasn’t always this way. An editorial written 20 years ago this month in the Journal by a group of well-known trauma surgeons at Kings County Hospital in Brooklyn lamented the controversy about the two disciplines at that time. There was substantial debate then regarding whether there was even a role for surgical critical care in the world of academic surgery.

Two major trauma organizations, EAST and AAST stepped up and provided a home for research and education in the field. One of the intriguing questions back then was the etiology of organ failure. Unfortunately, the study of critically ill medical patients was not able to answer this question easily, since the exact onset of the inciting factor was not easily recognized. But in trauma, we know exactly when the physiologic insult occurs, making research projects much more productive.

January 1992 marked the beginning of a time when we stopped trying to define what separates trauma and critical. It was the beginning of a period where trauma surgeons reasserted their commitment to total care, including critical care, and were not limited to only technical accomplishments in the operating room.

The new focus and title of the Journal recognizes that acute care surgery embodies many of the same operative and nonoperative management principles as trauma and critical care surgery. But I’m sure that we’ll see a new debate brewing that will be very similar to what occurred 20 years ago.

Reference: Trauma versus critical care: it is time to end the debate. J Trauma 32(1):1, 1992.