50.1 A system of traumatology

Trauma is so universal that the Declaration of Alma Ata included the care of the common injuries as an an essential part of Primary Care. This manual, the second in the series, describes how you as a non-specialist doctor can prevent much of the death and disability that are, the result of trauma—for every patient who dies, at least two are permanently disabled, most of them at or near the most productive period of their working lives.

Here are the injured patients you will see:—

(1) A few patients whose injuries threaten their lives, and who may die at various intervals after the accident: (a) Patients who die immediately, within minutes, from lacerations of the brain, brain stem’, or spinal cord. Most of these patients present at the mortuary, and account for about half of those who eventually die. (b) Patients who die within a few hours of the accident from bleeding into the skull, thorax, or abdomen, or from niultiple lesser injuries. (c) Patients who die days or weeks later from infection or multiple organ failure. There is little you can do for patients in groups (a) or (c); those in group (b) are your main challenge, because you can usually save them using quite simple technology—if you apply it soon enough—within four hours of the accident and if possible much sooner. This needs rapid transport and rapid surgery.

(2) Some patients who need admitting to hospital, but are in no danger of death. You will probably find that about half the beds in your hospital will be surgical and about half the patients in them will have been injured.

(3) Some patients with quite severe injuries whom you can treat as out–patients.

(4) Very many patients with only minor injuries. Although the injuries may look trivial, many of these patients are wage earners and want to be back at work quickly. If you don’t treat them carefully, complications may keep them away from work for weeks.
We have classified the methods of treatment that injured patients need into the three levels shown in Fig. 50-1. Like most classifications it is only a working compromise.

Level One, the care of a severely injured patient as a whole. When you first see a severely injured patient start with Section 51.3 and approach him systematically.

Level Two, the general methods. Some of these apply anywhere in the body and are those for shock (53.2), burns (58.1), split skin grafting (57.5), plastercraft (70.6), skin traction (70.10), skeletal traction (70.11), and amputations (56.1). Other general methods, such as opening and closing the abdomen, and making a colostomy, are described in Book One.

The general methods for particular regions of the body are those for injuries of a patient’s eyes (60.1), his face (61.1), his maxillofacial region (62.1), his lower jaw (62.7), his head (63.1), his spine (64.1), his chest (65.1), his abdomen (66.1), his lower urinary tract (68.1), and his hands (75.1).

Level Three, specific methods and specific injuries, form most of the book, and assume a knowledge of the methods in Level Two. For example, the methods for each particular amputation describe only the details peculiar to each site, and assume that you know the general method.

If a patient is seriously ill with many injuries, you may need to work through all three levels. But if he only has a minor injury, such as a subungual haematoma (75.5), you can work at Level Three only. You are unlikely to forget Level One, but you may forget to refer to the general methods in Level Two. For example, don’t treat a severe finger injury without following the ‘General method for a hand injury’ (75.1).

After first aid at the scene of the accident, we describe the care of an injured patient as a whole, the care of his airway, and the management of shock. Then come wounds, and with them artery, nerve, and tendon injuries. This is followed by methods for skin grafting and for the burns they are mostly used to treat.

Figure 50.1: THE STRUCTURE OF THIS BOOK is in three levels: (1) The care of a severely injured patient. (2) The general methods for the body as a whole and for partricular regions. (3) Specific methods and specific injuries. The patient shown here with the arrows was severely injured, so he needed the methods in Section 51.3 for a severe injury, and also those for airway obstruction (52.1), shock (53.2), a chest injury (65.1), and an intercostal drain (65.2 ).

After a brief discussion of radiation injuries, the rest of the book is arranged anatomically, starting at a patient’s head and working down his trunk. Then come general methods for his limbs (plaster, traction, and amputations), followed by specific injuries of his arms and then his legs, the more proximal ones first.
DIDIER (34) said that he had been hit on the scrotum by a bag of coffee. His scrotum was large and swollen and a quantity of bloody fluid was aspirated from it. Two days later he started vomiting and complained of abdominal pain. He had not passed flatus or a stool since admission. A strangulated inguinal hernia was diagnosed and 50 cm of necrotic gut was removed at laparotomy, after which he recovered uneventfully. LESSON patients quite often ascribe the onset of their condition to some quite coincidental trauma.