Lupine Publishers | Primary-Simultane Operation Pri Politrauma

 Lupine Publishers | Primary-Simultane Operation Pri Politrauma

Abstract

The author examines the current problems of modern medicine associated with the growth of injuries. In recent decades, not only has the number of injuries increased, but so does the severity of the damage. There were many problems, both in the organization of treatment of victims, and in the methods of surgical correction of injuries, especially if they are combined - multiple, and at the same time injured up to a dozen or even more persons. This is most often the case in road traffic accidents, and they sometimes occur on sections of highways, away from the regional and regional centers, where the main medical staff are concentrated, and in rural areas, where hospitals operate with very limited medical staff. For example, the staffing of the CRB usually provides surgical and trauma departments for 40-60 beds, that is, assistance is planned. or a surgeon, or a traumatologists, but often come persons with trauma of those organs and systems that are to be treated by a neurosurgeon, angiosurgeon and other specialists. The difficulty lies not only in the absence of them, but also in the tools for such operations. One doctor of the CRB receives a load, which in the regional center is allowed 5-10 or more specialists of surgical profile. In this situation, doctors of rural hospitals should have the technique to perform surgery in any form of trauma, but for this they must pass the school of training in leading surgical centers, and now they are mostly former students who know everything, but nothing they know how to do it. Admittedly, the increase in fatalities from injuries is partly due to this factor. The author gives an instructive observation of polytrauma, which fits into the context of the problem at hand.

Keywords: Polytrauma; Surgical treatment; Treatment

The Aim of the Study

To show the importance of the surgeon’s training in providing emergency care to victims of polytrauma

Introduction

Currently, there is a widespread increase in injuries, which is due to the rapid mechanization of work and recreation of the person. With the increase in injuries, there were many problems in the organization of treatment of victims with different types of injuries. The role of peripheral treatment facilities (mainly CRB) in providing effective assistance to traumatized persons has also increased, taking into account the mass migration of the population during the warmer months from cities to villages [1]. The structure of injuries has also changed significantly - the number of combined, multiple and combined multiple injuries is increasing. At the same time, the combined injury includes damage to different systems, and to multiple - the same [2]. With the one-time increase in the number of injured organs and systems, attitudes on surgical aggression have changed, and this has been greatly facilitated by recent advances in anesthesiology, allowing the most severe and pro-longed operations [3,4]. Although until very recently it was thought that expanding the volume of surgery on the human body is dangerous for his life [5,6]. However, the healing process of victims with polytrauma, dictates the need not only to own, but also to perform complex simulative manipulations on various organs and systems. In primary osteosynthesis performed in a combined injury, poor treatment results are twice as common as in other methods of cross-section, and the consolidation of the fracture occurs on average 1 month faster [7-9]. X-ray diagnosis is also needed to clarify the nature and type of injury, but it increases the radial effects on humans [10]. For this reason, it is necessary to resort to magnetic resonance imaging (MRI), as well as to be able to perform ancillary manipulations, including laparocenteza, in case of suspected abdominal injuries [11,12]. However, the leading role in the diagnosis of all injuries still belongs to clinical methods of examination, and they future doctors master during their studies at the university. On this basis, it is necessary to strengthen control over the quality of training of future health professionals in order to eliminate the appearance of ballast, which only interferes with the goal - reducing fatality from injuries, if in reducing their number they are powerless, for it is a national problem.

Material and Methods

In one of the district hospitals of Krasnodar region observed 59 victims with combined-multiple trauma, of which 41 (69%) were affected. primary simulates were performed (from 2 to 6). The rest had 18 (31%) Victims and this was due to their extremely severe condition, or because of the fracture of the bones of the base of the skull, or because of a closed heart injury, limited only to conservative methods of treatment - skeletal stretching, skeletal hanging of the lower limb. All of these patients died five to 18 hours after hospitalization. All patients (41) who had surgery, had multiple fractures of tubular bones, 32 - traumatic brain injury, 6 - closed rupture of abdominal organs, 3 - a fracture of the spine, 3 - pelvic bones, 12 - ribs, 10 – bones. A total of 204 organs and tissues were injured, ranging from 2 to 8 in one person. At the time of hospitalization, everyone had a second- to third-degree shock. The patients were between 13 and 52 years old. The diagnosis was based on clinical, X-ray, endoscopic, instrumental and laboratory examination. All of these patients had metal osteosynthesis of tubular bones (from 2 to 5, only 86), 4 - removed spleen, 2 - stitches on the liver, 6 - trepanation of the skull, etc. Of the 41 victims, 19 had simulated operations carried out 2-6 hours after hospitalization, and the rest within 1 day. The duration of surgical aggression ranged from 2 to 6 hours. Operations were performed under general end tracheal anesthesia with the use of controlled breathing hardware. Two traumatologists took part in the surgical intervention with or without the involvement of a surgeon. The 23-year-old man was admitted after a road accident in a state of extreme severity - pulse filamentous, AD - is not determined, breathing superficial 6-8 in 1 minute. On examination - on the face a lot of abrasions, a parting squint, pupils slightly enlarged and sluggishly react to light, in the left temporal area of the hematoma, from the left ear canal released a blood-bracing liquor (on the X-ray revealed a fracture of the temporal bones). The victim has a closed fracture of both forearms and lower third of the left thigh, and an open middle third of both shins and the middle third of the right thigh. The man was intoxicated. The trachea intubation was carried out and superficial anesthesia was carried out against the background of hardware breathing. After 6-8 hours, the blood pressure rose to 100/50 mm hg. pillar, but soon began to fall, and the stomach to increase in volume. Performed laparocenteza, which revealed blood in the abdominal cavity. Suspected two-moment rupture of the spleen and on vital signs performed laparotomy, which confirmed the diagnosis. A splenectomy was performed, and simultaneous operations were performed on the bone and joint system with the involvement of two more hospital traumatologists, i.e. two teams of specialists worked simultaneously. Sustained metorosemetalostheism of both tibia bones and on Rush of both femurs was performed. The simultaneous surgical creativity lasted about 6 hours, with 5 operations performed. Closed reposition of fragments of both forearms with plaster bandage. The general superficial anesthesia lasted about 2 days, and all this time the hardware breath was carried out. The hospital treatment lasted almost 3 months. There were no complications after the surgery. Gradually, all the fractures consolidated. However, he could not walk without crutches because of pain in his left hip joint. The resulting radiation load did not allow X-rays of this joint, and it was sent to the regional center for MRI. Magnetic resonance imaging unexpectedly revealed an old medial fracture of the cervix of the hip, which was the cause of pain and dysfunction of this joint. All previously diagnosed fractures have been consolidated. He refused hip neck surgery. For 1 year he was disabled in the 2nd group. Further communication with him was lost.

The Result

All the victims safely underwent surgery, but 2 (4.8%) after 3-5 days developed a fat embolism of the cerebral vessels, from which they died. Thus, out of 59 patients with polytrauma, only 20 (33.9%) died. Thirty-nine survivors had no early post-operative surgery. The duration of inpatient treatment in them on average was 45 days (36 to 90 days). The duration of incapacity in 5 patients was 6 months, 21 - 8 months, 10 - more than a year. 3 (7.7%) patients had a persistent disability - 2 it was caused by the consequences of a severe traumatic brain injury, and 1 - a false joint of the cervix of the hip.

Discussion

Thus, the performance of primary Simultane operations in combined-multiple trauma is practically and economically justified activity. They make it possible to successfully combat shock by creating stability of fragments and early activation of victims. The very method of operation, which allows to use existing metal structures effectively, is of great importance in the outcome of the operation. The materials presented in the article fully confirm the data of the literature that these operations reduce the number of postoperative complications by 2 times; on average for 1 month accelerate the consolidation of breaks, which accelerates the rehabilitation of victims. The cause of failure sits largely depends on the severity of the brain and heart injury, and this problem is now waiting to be solved.

Conclusion

Primary simultane operations in combined-multiple trauma can be attributed to the achievements of modern medicine. They allow doctors in polytrauma to actively influence the correction of homeostasis disorders and accelerate the consolidation of bone fractures, which has a clear economic effect. The introduction of new surgical technologies will lead to further progress in the treatment of polytrauma.

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Lupine Publishers | Acquired Digital Fibrokeratoma: A Rare Case Study

 Lupine Publishers | Surgery & Case Studies: Open Access Journal

 

Abstract

Acquired digital fibrokeratomas are a benign soft tissue tumor with typical appearance and anatomical locations. This lesion generally occurs in middle aged males with common sites of occurrence in the digits of upper or lower extremities. Previous case studies have reported incidences of this lesion appearing on heels of middle-aged males but are generally described as giant digital fibrokeratoma based on the lesion’s diameter. This case report describes an acquired digital fibrokeratoma in a pediatric female patient in an infrequent location.

Keywords: Acquired digital fibrokeratoma; Pediatric; Heel

Introduction

Acquired digital fibrokeratoma is a rare benign soft tissue tumor typically presenting on the hands and feet of middle-aged males. Clinical examination tends to reveal a solitary, round, firm, skin colored lesion less the 1 centimeter in diameter with either a sessile, dome-shaped or pedunculated base [1-4]. The patient’s history could entail a slowing-growing lesion without any known traumatic event which becomes painful upon compression through enclosed shoes. Diagnosis of the lesion is accomplished through clinical and physical examination, various biopsy techniques and histological and surgical pathology evaluation. Treatment is dependent on the patient’s desired outcomes. Conservative treatment entails offloading the lesion through various pads, proper shoe wear, or topical anesthetics. Surgical intervention entails removal of the lesion en-toto. Surgical intervention has been favored in recent times as the reoccurrence rate after excision has shown to be rare [1,2,5]. This case report describes an acquired digital fibrokeratoma in a pediatric female patient in an infrequent location.

Case Report

A 13-year-old female with past medical history significant for asthma, allergic rhinitis, atopic dermatitis, and eczema presented to clinic for a painful right heel lesion. The painful heel lesion began several months prior without any known traumatic events. Per the patient, the lesion began as a callus but progressed in size over the following months. Pain occurred with direct pressure secondary to enclosed shoe wear. Clinical examination revealed a firm, nonmobile, 7mm circular skin lesion with a pedunculated based located on the posterior aspect of the heel. Previous treatments of offloading pads and topical callus remover were ineffective. Surgical intervention was warranted due to failed conservative treatments and an MRI with and without contrast was obtained to further evaluate the lesion. Obtained MRI showed a soft tissue mass involving the dermis and epidermis along the posterior heel without extension into underlying osseous, ligaments or tendon structures. An excisional biopsy was planned for removal of the skin mass. Under monitored anesthesia care a 3:1 elipse incision was made which encompassed the skin lesion in total. The incision was deepened into the subcutaneous layer and was excised in a full thickness flap. The proximal pole of the lesion was tagged with a 4-0 prolene suture and sent for pathological and histological examination. The wound was closed in usual manner, with sterile dressing application. She was allowed to weight bear in a CAM boot and seen in office on post-operative day 10. At post-operative visit one, she reported no pain, the surgical incision was well-coapted and sutures were removed. She was instructed to transition out of the CAM boot and into regular shoes over the following week and given a 4 week follow up appointment. She canceled her second post-operative appointment and was not seen in clinic again. Pathological report obtained confirmed a diagnosis of acquired digital fibrokeratoma.

Discussion

In 1965, Steel published case reports on an unspecified periungual fibrous tumor which he described as a garlic-clove fibroma. Bart et al. reported on ten acral tumors in 1968 which were deemed similar to Steels previous findings but also resembled a “rudimentary supernumerary digit” with distinct histopathological findings and sites of occurrence. They termed the lesion as an acquired digital fibrokeratoma though suggested the lesion was not a fibroma rather a protrusion of the dermis [6,7]. Verallo et al also reported on 32 cases of similar lesions in 1968 as described by Bart et al. but with the expectation of six additional sites of occurrence. They suggested to omit the term “digital” from the name as described by Bart et al. to merit descriptive clarity. Reed et al. suggested the term acral to be utilized in describing the location of acquired fibrokeratomas. Recent case reports have described various locations of this lesion which lead authors to evolve the lesions descriptive terminology to acral fibrokeratoma [8-16]. Yi-Chiun Tsai et al. retrospectively reviewed 124 patients with a histopathological diagnosis of acquired digital fibrokeratoma over a 13-year period to characterize the distribution and surgical outcomes of these lesions. They found the mean age of occurrence to be 42 years, with a male predilection of 2:1, and 30/124 (24%) of the lesions located on nondigital areas. Overall recurrence rate after surgical resection was 5/124 (4%). Due to a low recurrence rate, surgical resection is generally recommended in treatment of these lesions. One most obtain a thorough history, clinical, physical, and histological evaluation for accurate diagnosis. Patients history general describes a slow growing lesion, without known trauma, which may become painful with compression. Physical examination reveals a small, firm, solitary, painless, skin tone color lesion which can arise in various locations. Under dermoscopy observation one visualizes a homogenous pale-yellow center surrounded by a hyperkeratotic scaly collarette with globular vessels located in the periphery of the lesion [16]. Histologically evaluation shows a benign fibroepithelial tumor, with acanthotic epidermis and thickened, often, branching rete ridges. The lesions core is formed by closely packed and interwoven collagen bundles which are generally vertically oriented. Elastic fibers are sparse but often the lesion is highly vascularized [1-4,17-19]. Differential diagnosis includes supernumerary digits in pediatric patients, cutaneous horns, pyogenic granuloma, exostosis keloid, dermatofibrosarcoma, eccrine poroma, neurofibroma and verruca [1,5,18]. The pathogenesis of acquired digital fibrokeratoma is unknown though mechanisms of occurrence have been proposed. Injury and minor trauma have been hypothesized as triggering factors, but case reports have not supported these mechanisms [1,18,20,21]. Kint et al. suggested neoformation of collagen produced acquired digital fibrokeratoma lesions based on histological findings of denser collagen fibers with capillaries and fibroblasts. They also described three types based on clinical and histological findings. Type I is noted to have a dome-shape and contains fibroblast between collagen bundles with fine elastic fibers and numerous capillaries in the dermis. Type II is a taller and hyperkeratotic lesion which contains more fibroblast and less elastic fibers then type I. Type III can be flat or dome-shaped and is defined by poor cellular structures and no elastic fibers [18].

In this case, the patients age, sex, and lesion location were atypical. Previous published case studies have reported on acquired digital fibrokeratoma located on a patient ‘s heel but are generally observed in middle aged males and described as giant acquired digital fibrokeratomas [10,12,13,20,22]. Majority of acquired digital fibrokeratoma measure less than 1cm in diameter. When lesions are greater than 1cm, they are described in the literature as a giant acquired digital fibrokeratomas [10,12,23,24]. To our knowledge, this is the first case report describing an acquired digital fibrokeratoma in a female pediatric patient located on the heel.

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Lupine Publishers | Medical Care is Not A Tourist Attraction: A Call for Global Standards and Governance

 Lupine Publishers | Surgery & Case Studies: Open Access Journal

Introduction

Short-term medical missions (STMMS) bring much needed medical care to some of the most underserved populations across the globe. They typically are staffed with well-meaning western medical professionals. These missions also attract students and other lay people looking for a meaningful experience to contribute to society through the delivery of healthcare. The typical volunteer experience includes a week to two- week time commitment, a modest monetary contribution, and plenty of photos to feed their social media accounts. Noelle Sullivan of Northwestern University noted “the most-cited figure estimates up to 10 million volunteers travel abroad annually, spending approximately $4 billion” [1]. The purpose of this article is to discuss the role of the layperson on STMM’s and appeal for the creation of global standards to eliminate the opportunity for unsafe and unethical care to the most vulnerable of people. The provision of medical care is meant to be delivered by those who are qualified and credentialed to alleviate suffering, reduce pain and improve overall quality of life. The concern is that the number of lay people participating in STMM’s will continue to grow and the health risks to vulnerable populations will become increasingly severe. Currently, there is no monitoring body or regulatory standard that is in place to protect people from the potential harm offered through the care of a STMM. It is presumed that most, if not all patients seeking care through the provision of a STMM see it as their only way to receive care otherwise unreachable due to access or monetary limitations.

Discussion

The Health Information and Privacy and Portability Act (HIPPA) is a United States policy that restricts access to patient’s personal health information and protects their identity and health status from public knowledge and viewing. The concern of the authors of this article is that volunteers on STMM’s may forgo the basic standards of HIPAA and privacy laws that are expected in their home countries. Medical providers have extensive training in HIPPA and privacy sensitivity as required by law. Infractions of HIPPA policies can lead to termination of employment and even a monetary fine. In an article by Thompson LA, Dawson K, Ferdig R et al. [2] medical students at the University of Florida were most likely to have potential HIPPA violations on their social media accounts when they posted photos from their experience on a STMM. Medical students have training in HIPPA and privacy sensitivity and yet, have demonstrated a lapse of application abroad, so what can we expect of the untrained lay volunteer? A limited literature review was conducted for the purposes of writing this article through the Syracuse University Library. Impens A [3] Initial results using the keywords “short term medical mission” resulted in 26,750 articles. The search was further restricted using: “short term medical mission, staffing, ethics, criteria, lay volunteer” resulting in 138 articles and after laborious review, not one article explicitly addressed the specific restrictions of the lay or non-medical volunteer. Certainly, the role of the licensed Grennan T clinician or student enrolled in a clinically based education program is much easier to understand than the role of the lay person on a STMMS [4]. There is a paucity of information as to how STMMS utilize lay people and yet there is a high potential for harm and violation of ethical standards. Lasker et al. [5] discusses how volunteers are selected and stated that 76-100% of the organizations accepts everyone who apply and can afford the participation and travel fees. Although these institutions believe that everyone has something to contribute, they can be doing more harm than good. The negative consequences that can arise are downplayed, giving fuel to the acceptance and dominance to the idea that some care is better than no care, regardless of the ethical infractions. These thoughts contribute to the progression of the negative concepts of “voluntourism”, “poverty porn” and “white savior syndrome”. Even more alarming is the opportunity for the lay volunteer to “play doctor” and assist with medical procedures and interventions. For example, Unite for Site advertises to volunteer with them and watch “sight restoring surgeries” (https://www.uniteforsight.org/volunteer-abroad/interests) [6] and yet they provide one of the most detailed guidelines on best and worst practices for medical missions.

The provision of medical care should be provided by the most qualified, the most competent, at the highest ethical standards available. No element of a person’s ability to pay, education level, or cultural understanding of healthcare should offer the opportunity for anyone to lower these standards. It is not difficult to find posted on social media the very public display of very private medical interventions and procedures on either individual accounts or organizational accounts. An example of an organization that is a blatant violator of the sanctity of privacy in medical care is the Moreano World Medical Mission and their public Facebook page. Posted on their public Facebook page you can find pictures of patients before, during, and after their surgical treatment. Posed with them are the volunteers grinning ear to ear displaying their joy in “making a difference” while blithely ignoring this person’s right to privacy and dignity. The Moreano World Mission is only one of hundreds of organizations that are unregulated and allow non-medical participants to engage in the violation of the medical ethics and is one of the worst offenders of social justice and human rights. They disregard basic medical ethical standards and with no governing body monitoring them, they will continue to exploit the most vulnerable populations with little to no restriction.

Not only are there privacy concerns with STMMs, but even more concerning is the opportunity for a lay person to play “doctor” while on these voluntourism trips. In an advertisement for the international volunteer organization Projects Abroad, students as young as age 15 can “get the real-world clinical experience you need to excel in a medical career”. Adam O, age 17, writes in his Projects Abroad testimonial how he was able to see three deliveries and even one delivery of a 16-year girl who did not make it to the delivery room. He also writes about how he was given the opportunity to treat pediatric patients for ringworm, dress their wounds, and distribute their “anti- worm medication”. Kimberly M wrote about how great it was to be able to watch multiple surgeries while in Mongolia as it is difficult to observe surgeries in her home country of the United Kingdom. Even Unite for Site, advertises to the opportunity to volunteer with them and watch “sight restoring surgeries” (https://www.uniteforsight.org/volunteer abroad/ interests) [6] and yet they provide one of the most detailed guidelines of best and worst practices for STMMs. It is concerning to think that even today that the basic principles of ethics can be easily tossed aside for idle curiosity. Additionally, some medical providers may find themselves practicing outside their scope of expertise in response to the lack of specialists in the area. We would not allow a General Practitioner to perform eye surgery, why is this standard different outside our borders? Some of the worst offenders are students. Students enrolled in clinical education programs at home often find themselves with opportunities to practice above their current level of training. They may see it as an opportunity to practice and perfect with little consequence [7]. STMM’s largely are self-serving, ineffective, pose burdens to the host community and fail to provide continuity of care and sustainability plans. STMM’s provide minimal benefit to the host community and take advantage of the vulnerability of the communities they invade [8]. They fall under the misguided notion that some care is better than providing none. It’s very difficult for these communities to say no because even though the missions may not directly satisfy their most pressing needs, they still lack resources.

Recommendations

While no orientation can help prepare someone for what is to come on a STMMs, there are several things that organizations can do in order to prevent some unethical practices. First, all volunteer organizations should cease and desist all opportunities that allows under qualified or unqualified persons to practice medicine. Second, an appeal to countries across the globe and the World Health Organization to create policies that condemn and restrict organizations that run STMMs that do not provide ethical and safe medical care. Third, a request for the formation of governing body to monitor, license and oversee the burgeoning growth of organizations providing medical care to vulnerable populations in this format. Fourth and not final, the development of global policies and policing of STMM’s to ensure that health as a human right extends to its fullest meaning.

Conclusion

No person should be exposed to unethical health practices for the curiosity of another. The request for a regulatory body is urged to the World Health Organization (WHO) and the national and local governments of the most frequented countries by STMM’s. The vulnerability of the population entails serious risks of exploitation [9]. The standards of medical care and ethical practice should not waiver with geography or be compromised by the curiosity of another. Health is a human right and healthcare with basic human dignity is inherent in that right.

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