Search

Introduction: The introduction of Modernising Medical Careers (MMC) is likely to reduce specialist registrar (SpR) operative experience during higher surgical training (HST). A further negative impact on training by local Independent Sector Treatment Centres (ISTCs) could reduce experience, and thus competence, in primary joint arthroplasty at completion of higher surgical training., Patients and Methods: Retrospective case note and radiograph analysis of patients receiving primary hip and knee arthroplasty in a teaching hospital, before and after the establishment of a local ISTC. Patients and operative details were recorded from the selected case notes. Corresponding radiographs were assessed and the severity of the disease process assessed., Results: Fewer primary hip and knee replacements were performed by SpRs in the time period after the establishment of an ISTC., Conclusions: ISTCs may adversely affect SpR training in primary joint arthroplasty.

The authors studied the utility of the DSM-IV Global Assessment of Functioning (GAF) scale for improving interdisciplinary communication about patient care. Discharge GAF scores for 165 discharged inpatients were computer generated by 13 trained unit social workers and derived by eight psychiatrists on the basis of their clinical impressions. Differences between the scores obtained by the two disciplinary groups were tested by using the paired t test and the nonparametric signed-rank test. Agreement between scores for various GAF categories was tested with kappa agreement indexes. Interdisciplinary agreement on discharge GAF scores was observed across diagnostic categories and across most categories of length of stay. The results suggest that social workers, after receiving systematic training in computer-based GAF reports, can provide reasonable assessments of clients' functioning.

Background: Following the crash of a Boeing 737-400 aircraft on the M1 motorway at Kegworth, near Nottingham, England, on January 8, 1989, it became apparent that a large number of pelvic and lower limb injuries had been sustained by the survivors. Had there been a fire, these injuries would have severely hindered the ability of the occupants to escape. The mechanism of pelvic and lower limb injuries in impact accidents previously has been related to flailing of the limbs and axial loading of the femur as in automobile accidents., Hypothesis: A bending load is the primary mechanism of femoral fracture in an impact aircraft accident rather than an axial load., Methods: Two methods of study have been used to investigate the impact biomechanics of the pelvis and lower limb: a) clinical review of the injuries sustained in the M1 Kegworth accident; and b) impact testing., Results: A clinical review of the M1 aircrash survivors suggested that axial loading was not the primary mechanism causing femoral fractures and suggested that a bending load might be applied to the femur. Impact testing confirmed that axial loading of the femur did not appear to be significant., Conclusions: Our study suggests that in the presence of intact occupant protection systems, a femoral bending mechanism involving the front seat spar of passenger seats is a primary cause of femoral fracture in an impact aircraft accident.

Only 10 occupants escaped uninjured from the wreckage of the East Midlands Boeing 737/400 aircraft accident. The remaining 116 suffered injuries similar in pattern, but ranging in severity from simple bruising to fatal crushing trauma. Overall, the individual's degree of injury and likelihood of death was proportional to the local structural damage of the aircraft. Limb injuries were particularly severe in the forward section of the wreckage where the floor failed. In areas where structural damage appeared to be survivable, a number of passengers suffered disproportionately severe head injuries. Many of these had trauma to the posterior aspect of their head, some of whom died as a result. It is likely that these injuries were caused by falling overhead lockers or unrestrained cabin furniture. The significance of these injuries and their future prevention is discussed.

Of the initial 87 survivors of the East Midlands Boeing 737/400 aircraft, 77 sustained head and facial trauma during the crash, 45 of whom were rendered unconscious. There were 21 who received injuries to the back of their head, including 5 of the 6 severely head-injured adults. Those passengers who adopted the fully flexed "brace" position for crash-landing achieved significant protection against head injury, concussion, and injuries from behind irrespective of local aircraft structural damage. A computer graphics simulation developed by a commercial firm (H. W. Structures, Ltd.) using the predicted crash pulse of the accident has validated these clinical findings and allows theoretical biomechanical modeling for the design of occupant protection systems in the future. Although the major role of structural failure should not be forgotten, bracing maximizes the chance of uninjured survival in the current generation of aircraft and should be demonstrated and practiced as a pre-flight routine.

The Abbreviated Injury Scale (AIS) score and the Injury Severity Score (ISS) were calculated for all passengers and crew of the M1 Kegworth aircraft crash. Regional injury scores were significantly higher in nonsurvivors than survivors of the impact. Mortality and ISSs were found to correlate with the structural damage sustained by the aircraft. The use of injury scoring has highlighted variations in the severity of injuries sustained by occupants involved in an impact crash of an airliner. This information has demonstrated that other factors in addition to the force of the impact were involved in the causation of injury, such as structural integrity, attempts by occupants to protect adjoining passengers, and rear-facing seats.

The incidence of a delay in the diagnosis of injuries from the 83 survivors of the M1 aircraft accident is described. A total of 32 injuries in 25 patients were not initially diagnosed, nine each in the upper and lower limbs and 14 in the spine. This was equivalent to 9.6 per cent of all the major injuries suffered by the survivors. Five patients required surgery for a late diagnosed injury. The incidence of a delayed diagnosis injury (DDI) was not related to the overall severity of injury. Delay in diagnosis of injuries after such a major accident was attributable to failure of clinical examination, failure to radiograph symptomatic areas and failure of radiographic interpretation.

The 79 survivors of the M1 aircrash have been assessed at an average of great britain 1 year after the accident. Return to work, continued hospital care and recovery from injuries has been found to be related to the severity of injury. The 188 pelvic and limb fractures have been reviewed and the incidence of complications from these injuries has been low. Spinal and lower limb injuries account for the majority of the residual disability.

There were 83 survivors of the M1 aircrash admitted to hospital; of these, 28 patients sustained a total of 40 open fractures. These open fractures were classified as 19 grade 3, 16 grade 2 and five grade 1. There were six upper limb fractures and 34 lower limb fractures. A high proportion of grade 3 open fractures were identified in this series (47 per cent) and one-half of these occurred at or below the ankle. This reflected the high energy and direction of the forces involved in the aircrash. The early results in terms of the incidence of wound infection (15 per cent), delayed wound healing (7.5 per cent) and skin flap necrosis (7.5 per cent) were similar to other series. The controversy over whether to leave grade 3 wounds open or closed was not clarified by this study, but the closure of grade 3 wounds after internal fixation is to be avoided. This study emphasizes the need for provision of adequate specialist manpower, equipment and resources to manage the unexpected major disaster successfully.

Following the M1 air crash on 8 January 1989, 39 casualties were taken to the Queen's Medical Centre, Nottingham. A team of 31 radiographers and four radiologists used all five X-ray rooms adjacent to the Accident and Emergency Department. Patients with head and spinal injuries were further assessed in the CT suite by four radiographers and a neuroradiologist. The volume of work in the first few hours and in the subsequent days is described. All radiological examinations have been reviewed and the injuries, including those missed at initial assessment, are discussed. The role of the radiologists was to issue immediate reports, manage examinations so as to minimize any delay and assess the need for further specialized investigation. Important problems were identified, specifically: the call-out system; patient deterioration and lack of resuscitation equipment; patient flow; documentation; radiology equipment; and missed injuries. These problems are discussed and recommendations are made for X-ray Departments in dealing with disasters.

The general surgical consequences of the M1 Kegworth air crash are described. Considering the severe nature of the injuries sustained by the survivors, surprisingly few required general surgical intervention. Intra-abdominal injuries were rare despite the abdomen's apparent vulnerability to injury; only five laparotomies were performed. However, 30 (34%) of survivors demonstrated significant bruising from lap belts and 13 patients had haematuria. The majority of operations carried out were orthopaedic related.

On 8 January 1989 at 20:25 h, a British Midland Boeing 737/400 on approach to East Midlands Airport crashed across the M1 motorway with the immediate loss of 39 lives from the 126 people on board. In the aftermath of the accident a clinical review was commenced to determine the mechanisms of injury in the 87 initial survivors and hopefully provide data to improve commercial aircraft safety in the future. Seventy-seven survivors sustained head and facial trauma in the crash, 45 of whom had periods of amnesia surrounding the event. Twenty-one received injuries from behind, including five of the six severely head-injured adults. Loss of consciousness and duration of amnesia were directly related to the degree of superficial head trauma. Adoption of the fully flexed brace position for crash-landing offered significant protection from head injury and concussion, and possibly reduced injuries from behind. Suggestions are made for potentially improving the survivability of aircraft accidents.

On 8 January 1989, a Boeing 737 carrying 126 passengers and crew crashed onto the M1 motorway killing 39 passengers. Of 87 initial survivors, 74 had major injuries making this an unusual accident as most aircraft crashes result in very few severely injured survivors. This prompted the setting up of a major study group, the Nottingham, Leicester, Derby, Belfast Study Group (NLDB) to examine in detail the accident and its aftermath. This paper is part of that work and is an initial survey of the thoracic injuries sustained by the 87 survivors. Twenty-three passengers sustained major chest trauma and all had major injury to other parts of the body. Five of these patients died within 12 h of admission. Various patterns of chest trauma emerged from this study, including an increasing incidence of rib fractures with age and a distinctive pattern of upper zone pulmonary contusion in younger patients.