History Taking & Clinical Examination : Its Importance
In the present day medicine, detailed history taking and methodical clinical examination, a sine qua non for diagnosis and treatment, appears to have lost its importance. Cursory examination by the juniors, rarely by the seniors, if they have time has become the routine. Vital information needing a questioning mind, vigilant eyes and prehensile hands are thereby missed.
Our people are God fearing. For good results the doctor gets the credit and whenever bad, God is blamed. Fortunately they are not legal minded otherwise things might have been different. Three cases are presented as an eye opener :
1) One Mr X 45 years old reported to OPD JIMCH (Jahurul Islam Medical College Hospital) with swelling of left knee and occasional locking for one year. He had a history of Assault about ll/2 year back - injury to his knee by a bamboo spike. He was initially treated locally, possibly with antibiotics. Then he went to a Premier Medical College Hospital of Bangladesh. He was diagnosed as Traumatic Synovitis and Synovectomy was done.
On Examination by us : Operation scar in front of the knee was present. There was swelling of the knee with effusion and synovial thickening. Occasional creps also noted. While examining he said that sometimes his knee got stuck during movement and sudden jerk relieved it. He felt something moving inside. This arose a suspicion of loose body inside the joint. X-ray showed erosion of the articular surface of the femur. Immediately the joint was opened, fluid gushed forth and a funny looking dark object was visible. It was taken out - a conical piece of bamboo 21/2 long, 3/4" diameter at it's base. The wound after thorough toilet was closed. It healed with primary intention and the patient never returned after that.
The concept of ATLS started in 1976, after a tragic accident which ultimately resulted in conceptualizing the Advanced Trauma Life Support Course. A Nebraskan (USA) Surgeon piloting his small plane crushed into the woods. The Surgeon was seriously injured, his wife died instantly and four children were also injured. Reportedly the initial care received by the surgeon and his children was far below the minimum standard of trauma care. Recognizing this, the Surgeon wrote" Whenlcan provide better care in the field with limited resources than what my children and I received at the primary care facility-there is something wrong in the system and the system has to be changed."
This has ultimately resulted in an ATLS course by the American College of Surgeons and they have adopted it in 1979.
Trauma without respect for age swift in onset and slow in recovery, presents many pitfalls for the responsible physician carrying for the trauma patients. Trauma is merceless in its lethal and mangling pathways through our young and potentially productive members of the society. Prevention is the best cure but when prevention fails, the surgeon and physician must be sufficiently knowledgeable to meet the injured patient needs and reduce the morbidity and mortality of trauma. For every person dies due to injury there are 2-3 disabled persons in the society.
Injured patient must thoroughly and repeatedly examined and management should be started according to priority basis immediately. If patients condition exceeds the treating hospital treatment capabilities then the process of transferring the patient is initiated as soon as possible. Physician will be oriented to initial assessment and management of trauma victim with emphasis on first hour initial assessment, primary management starting from the time and site of accident followed by stabilization of the patient.
In this issue we have published an extensive review article on ATLS which I think will be emensly beneficial for all who treats trauma patients.
Treatment of the injured patients takes lot of time and energy all over the world and more so in our country with limited resources and manpower, If we want to maximize our services to the poor patient we have to have a new look to the whole situation of the hospital management around the country.
The cost of Road accident has been analyzed by Transport Reseasrch by Laboratory (TRL) Fouracre & Jacobs-76 showed that the accident costs were equivalent in any country be it developed or developing to approximately 1% of Annual Gross National Product (GNP) in current prices this suggests that it is costing Indonesia 600 million pound sterlingper annum, Pakistan 260 million, Egypt 200 million, Korea 60 million and probably in Bangladesh about 200 million pound sterling.
The cost of the injury management is very high. About 5 Billion US dollar are spent in UK for the injury management in USA 75-100 Billion are spent for injury management directly or indirectly. But very little is spent on injury research. In our country we do not have any exact statistics but we know that the cost of this management is very high.
If substantial pain, grief and suffering caused by road accident is not sufficient enough motivation for reduction of accidents, then there is very strong economic case to be made in the significant loss of resources each year due to accidents.
The first article of this issue is on investigation on length of hospital stay of trauma patients which shows about 47% of patients stay in hospitals for more than 3 weeks. The economic aspects of this long stay should also be considered by all.
It is about time that wo understand the need for Medical Audit: By introducing audi t to different departments in our hospitals we can look into our work and scrutinise them and try to modify them to imporve ourselves. Medical Audit is now seen throughout the world as a necessary requirement to improve the health care. Pressures from public has been instrumental in creating present environment in Medical Audit. In Bangladesh we are not yet auditing most of our departments and hospitals. 1 feel there is great need for introduction of audit into our departments.
Orthopaedic Audit will lead to improvements in the quality of care through the setting of standards by reviewing our work and Implementing the changes that may be needed. Audit educates us through fuller understanding of the patients and providers.
The Challenge of Trauma-Traumatology Unit
Last year, WHO declared their Annual slogan as "Handle life with care-prevent violence & negligence". We have observed the world day on 7th April in a befitting manner & expressed our ideas on the theme of WHO throughout the year. In reality, the present situation of our society is very alarming in respect of RTA, violence & terrorism. Negligence is the rule in all spheres of life. In hospitals, number of casualty patients are increasing manifold from traffic accidents & from violence of different activities. This large amount of trauma patients offer a challenge to the existing health care facilities of our country.
From a district hospital to a medical college hospital, even in RIHD (Rehabilitation Institute & Hospital for Disabled) there is yet to develop a comprehensive unit for managing all sorts of casualty patients. Here, there is a hope, the 100 beded traumatology unit is waiting for its official inauguration. The project is taken under the scheme of 'Further development of RIHD' from development budget. In fact, RIHD should be kept as an academic Institute & the greater load of trauma patients could easily be dealt with the trauma unit. It is a challenge to the authority of the hospital to develop an ideal institution from the beginning. I hope with the cooperation of all cornurs the traumatology unit will fulfil our aspiration & would be able to face the challenge of trauma in ensuing years.
INCORPORATION OF THE MANAGEMENT OF TRAUMA IN PRIMARY HEALTH CARE IN BANGLADESH AND A PROPOSED SETUP OF TRAUMA CENTRE IN THE COUNTRY
The present status of trauma management in periphery has no definite plan, that is also true in the management of accident & mass accidents as experienced in recent past years.
The on going article is a suggestion of how to integrate trauma from grass root level to the National Institute based in Dhaka through Medical College Hospital.
The contents of the article was read in the Intercountry seminar on -Road Accident Centres Programme Development, organized by the British Technical Assistance Programme (ODA), WHO & Ministry of Health & Family Welfare, Dhaka, Bangladesh.
A suggested setup of trauma centre based on Health Institution i,e, Thana Health Complex, District Hospital, Medical College College Hospital has been described suggested manpower & the training espect also describen. the plas has been based considering the health for all by the year 2000 AD.
Since the starting of "Mukti Bahini" ward in Dhaka Medical College Hospital the demand for trauma service in the country was quickly felt after liberation and was met by a very able and dedicated person without whose effort we will not be here today Dr. R. J. Garst started the Othopaedic Hospital in Shaheed Sarwardy Hospital Complex in 1972 and also started the post graduate orthopaedic training. New hospital building at the present site and started funtioning in 1976 with 400 orthopaedic and traumatic beds. From one orthopaedic surgeon in 1972 in the whole country to 65 working today and 10 working abroad are all produced from this institute (RIHD) situated in the some hospital.
Orthopaedics in Bangladesh has come a long way in a very short time. Now at this level we must think about Orthopaedic research. Orthopaedic research of today is really the Orthopaedic treatment of tomorrow. I think we can be proud of the fact that there has been more progress in Orthopaedic & traumatic surgery than in any other surgical discipline after the indifendence. But the problem is that the very success of the country has meant that treatment we can offer and which is now demanded by the public has increased our work much that we have little time for clinical research and academic work. But still that should not be the excuse and we should start clinical research atleast at any cost.
By Research, I dont mean that it has to use Laboratories or animal experiment finding out how club foot after operation has recurred would count as a very useful piece of research.
We must try to find out what factor is tending to limit or inlimit research work at this stage.
There are mam- factors inhibiting our research work. Above aH I wiH say the willingness to devote time, enthusiasm to continue and lack of recognition of the work in the society are the main factors. Money, lack
of fascillities are other problem. Considering all these of couse, a vital factor in research is time and lack of time is most important diement that discourage research.
In a pratical subject like Orthopaedic surgery, time for research is always in competition with the needs of clinical activity. We must increase the number of consultants at the institution to give more time in research. Consultant looking up 130 bed in indoor and both casualty & outdoor will not have time for research as it is now at RIHD.
Above all the most important ingradient in research is the right man. What sort of person is he or she? He must have an enquiring mind, and I hope that all of us have some element of that in our make up. He must be a person with ideas.
Having identified a problem, a true research man must have the energy and enthusiasm to pursue it until he finds some answer. It is often laborious and sometimes tedins but alway rewarding, even when answer does not turn out to be what was hoped for.
A will designed prospectus survey or trial is the keystone of clinical research once the problem of question has been identified, there is no doubt in my mind that the only way to proceed is to set up special clinics. We must try to set up Hand clinic. Polio clinic CP clinic clubfort time etc. at this stage in the institutions.
Good documentation is the next vital requivements. Photographs are another important tool of clinical research.
In spite of the difficulties that there may be, any one. any where with good clinical acumen, a suitable problem to solve, the capacity to organise perhaps against the odds and the determination and willingness to give some of his time, can add his contribution to clinical research - to that continuous and laborious search after truth may continue.
Arthroscopy is one of the most important advances is Orthopaedics. Arthroscope has dramatically changed the way in which orthopaedic surgeons treat variety of joint ailments-espicially of the Knee. Although viewing of Cadavar Joint cavity was reported by Professor TAKAGI of Tokyo in 1918 the enthusiasm for the technique developed in by publication of Atlas of Arthroscopy by WATANABE in 1957. Arthrocopy was popularised by CASSCELLS and JACKSON (U.S.A.)
Arthroscopy is an accepted way of management in joint diseases. Although Arthroscope has been avaible in Bangladesh since 1981 il was not available for routine Institutional use. There has been an adition of arthroscope in R I H D in last few months by courtesy of W.I I.O.
The availabality of arthroscope in R I H D will enable us to leach the students the new technique and also to improve the management of Joint problems. Recently visiting surgeon Dr. Donald Sullivan from Florida
U.S.A. has showed us newer techniques of arthroscopy. We hope to develop this technique in future.
This issue of the journal was due In January '89. There has been delay. An editor could show a number of excuses but I shall not. I bear this failure on my shoulder. Last year, there, has been distortion in many spheres of work and activity. We have taken few initiative on epidcmiological survey of bone cancer side-Swipe Injury etc. but we could not follow that. Serious breakdown of contact with patients occured due to frequent communications failure due to political unrest & unthinkable flood situation. I do agree with the editorial comment of Dr G Walker about some Important scrvey works in relation to Orthopaedics. But very often, as he has pointed also, we are mostly occupied with trauma cases and with service lo hospilal only. Surveys are mullidiscipllnary work . We should develop coordination with multiple forces before step into this venture.
Every effort has been made to improve this issue from the previous one. I earnestly Invite more articles from the country. Hope a better issue In future but that should be a regular one.
Again, I must give thanks to the men who made it possible to publish the journal, at least regularly. Specially Dr Rafiqul Islam and Dr. R. R. Kairy who has helped me all the way.
Sir Reginald Watson Jones, Who died in 1972 at the age of 70, was probably the most colourful & dynamic of all the fracture Surgeons of his time. His attitude towards fracture treatment is perhaps best summed up in the following quotation made in a speech in his honour New York — "To Sir Reginald Watson Jones, always positive, never in doubt & by the grace of God usually right"! His views on the union of fractures were much influenced by his predecessors at Liver Pool, Sir Robert Jones & Hugh Owen Thomas. These views may be summarised in the statements made in his book that" The cause of non-union of fractures is inadequate immobilisation" and that "non-union of fractures due to failure of Surgeons much more than to the failure of Osteoblasts." This has led to the unfair criticism that Sir Reginald would immobilise a fracture indefinitely in plaster to the detriment of limb function, a criticism which also led the opposite school of fracture treatment at St. Thomas' Hospital to deride prolonged immobilisation with the comment "Plaster means Disaster." Sir Reginald who essentially a conservative surgeon as far as fracture treatment was concerned and once describe himself as a 'Physicion destined to the role of a Surgeon. He would never have agreed with the philosophy of the Swiss school of Surgeons who have advocated primary internal fixation of fractures to avoid 'the fracture disease' of prolonged immobilisation. The only fracture disease that Sir Reginald recognised was that brought about by iatrogenie diasters and on many occasions showed conclusively that prolonged immobilisation of normal joints did not produce stiffness.
The first issue of Bangladesh Orthopaedic journal is well received. We have unexpected encouragement from home and abroad. It is a great pride and honour for those who have baen associated with the establishment, survival and expansion of the orthopaedic service in this country It is heartening that the 'Bangladesh Orthopaedic Society is now more organised and publishing the second issue.-From this issue the name of the journal is changed to "The Journal of Bangladesh Orthopaedic Society' instead of "Bangladesh Orthopaedic Journal" From now onward we are publishing contributions from esteemed well wishers from abroad. We hope this will help us to be established firmly in our course.
The ostablishment of organised orthopaedic service is new in this country. Recently it has been started in few district hospitals, otherwise it is limited only to urban areas. Even in these centres, service facilities available are not satisfactory because of the nonavailability of the essential materials and equipments. This is dishearten ng when well trained orthopaedic surgeons are comming back home and very good orthopaedic surgeons are being trained in the country. It is essential that at least basic materials should be provided so that these highly trained technical men can be used to help the poor people of this country. It has been found that x-rays, plasters and dressing materials and few orthopaedic tools can render very valuable service.
The orthopaedic service should be expanded to the periphery to prevent complications following injuries and fractures. Still the majority of the people are being treated by village doctors. Many disasterous iatrogenic complications have been reported. This will happen if the bone setters are not prevented to do so and proper service facilities are not provided to the people. The members of the society have great role to play in orthopaedic problems including trauma. Preventive measures are being stressed by which many orthopaedic conditions can be prevented, disease like bone tuberculosis and poliomyelities can also be eradicated.
The year of the disabled has been observed. Many seminers and workshops have been organised with a lot of promise to our millions of disabled people. But unfortunately nothing has been done substantively. Yet there is no national programme for the disabled and no legislative for the disabled, and the right of the disabled is being ignored. We should have done better. Invalid aids are being supplied from one centre only with inadequate supply and old fashioned prosth-etics and orthotics with unsatisfactoly result. Most of this aids again are not suitable for our rural conditions. We have noticed many improvised aids prepared by the patient themselves to suit their need are better, cheaper and readily available. The example should encourage us to venture for our own aids from local resources.
Research facilities should be encouraged to find out own system of treatment with our own resources. Many conditions like bone tuberculosis and poliomyelitis are our own problem. Yet their is no survey to find out how many people are suffering from these diseases. It is hoped that the journal will be able to awaken the couci-ousness of Medical Profession and the policy makers to formulate Policies Suitable for our people. Time has come to extend the basic Orthopaedic Services at the Periphery to minimize the disabling conditions.
In Conclusion it is our earnest hope that the members of the medical profession in general, and the Orthopaedic Surgeons in Particular will come forward to expand the Orthopaedic Service in this country.
It is our priveleadge and honour to introduce the inaugural issue of "Bangladesh Orthopaedic Journal". We should have done it earlier. Attempts to organise Bangladesh Orthopaedic Society were made several times. But unfgrtunately many members of the society left the country for better prospects abroad. Finally we are publishing this journal from R.I.H.D. I hope Bangladesh Orthopaedic Society will publish it bi-annualy regularly from the next issue.
The main objective behind the publication of this journal is to share our experience with others. We will try to give our people here what is modern and good. We will try to uphold the standard of the journal and maintain its aim that is the advancement of Orthopaedic Surgery.
Treatment of musculo skeletal diseases used to be done by the general surgeons. Attempts to organise this service before remained limited to individual frustrating experience. Only after the liberation war the importance of orthopaedic service grew tremendously because of war injured. For the last eight years we had our successes and failures but had no media to convey to our people. It is during this period that orthopaedic services In Bangladesh established firmly as a speciality and expanded rapidly to be available for whole of the country.
Eight years ago Dr. Garst started this institute in a room of S;S. Hospital to organise orthopaedic service for the war wounded freedom fighters. After eight years it has developed as the central institute of orthopaedic services and training for doctors and other paramedics for orthopaedics. At times it used to appear that this institute may not survive for long. It was Dr. Garst who pioneered it, expanded it and made it the central institute for teaching, treatment and rehabilitation. Behind him were the dedications of those locals and foreign •consultants without whom it would have been impossible to survive.
It is a great honour for me to write the editorial of this inaugural issue when R.I.H.D. is going to be inaugurated and the year of the disabled is going to be celebrated. 1t is a great occasion for us and will be remembered with much envy by who will come after us. Many of us who shared the load of its initial setup are not here to rejoice this great occasion of opening of this hospital. I remember with gratitude those freedom fighters and patients who helped us to build this great institute in their pains and sorrow, loss and •death, I remember those doctors, nurses and paramedics whose dedication and devotion motivated many more to make it the central institute of orthopaedics and rehabiltation. This inaugural issue of Bangladesh Orthopaedic Journal is being dedicated to the name of those •who were with us, are now with us, arid will be with us.