–Interview with Zhao Gang, Director of Orthopaedic Trauma Department and Director of Emergency Surgery Department of Shandong Qianfoshan Hospital Published: 2012-08-15 With the rapid development of the society and economy, the incidence of severe trauma, especially high-energy trauma, caused by transportation, machinery and other factors is increasing, and it has become the most dangerous enemy of our modern life. Zhao Gang, Department of Orthopedics, Thousand Buddha Mountain Hospital, Shandong Province Most of the consequences of severe trauma is amputation, which is still in the development of China, not yet widespread use of expensive prosthetic limbs, many patients lose their ability to work or even to take care of their own lives, which is a heavy burden on the family and the society. Preserving the residual limb, repairing and reconstructing the function as much as possible, of course, has become a big challenge for many clinicians in treating traumatic near amputation injuries. Over the years, Dr. Zhao has been committed to solving this medical problem. Health is important, and lives depend on it. As an emergency surgeon, Dr. Zhao’s work is very tiring, but “it’s hard work and fun”. “When a patient puts his life’s hope in us, we carry the weight of a life; when a patient is successfully treated, we give him a continuation of life, and that kind of joy and happy fulfillment is self-evident.” Reality left him, the most heartbreaking, is: he watched a number of patients on the verge of amputation injuries because of bouncing around a few big hospitals, still can not be saved, missed the best time to save, before he found him, he thought to himself: such a patient if all of a sudden to find him how good it is ah! The danger of polytrauma: never a simple “1 + 1 = 2” impact With the development of industry, agriculture, transportation and construction, and lagging traffic management, road expansion and poor social security can lead to an increase in the incidence of trauma. According to the statistics of the Western Pacific World Health Organization, one person dies under the wheel in every 50s in the world. The incidence of trauma in our country was seventh in 1957. In 1995, it rose to the fourth place after cardiovascular and cerebrovascular diseases and tumor mortality. In our country every year about more than 10,000 people died of trauma, more than 200,000 people disabled due to injury, more than a million people injured. According to the statistics of post-injury deaths, 50% of the deaths occur immediately after the injury; 30% of the early deaths; 20% of the late deaths, 80% of which died of infection or multiple organ failure. Therefore, near amputation injury, multiple injuries have become a major social nuisance. Director Zhao said that the clinical incidence of multiple trauma is high, the incidence of most of the young, healthy; healthy, labor force of young adults, and often there are multiple trauma condition is complex, easy to miss the diagnosis of the situation. The complexity of polytrauma management requires the synergy of various departments, but they often lose sight of each other. Combined with many years of clinical experience, Director Zhao said that the harm of multiple trauma in many cases is immeasurable, the injured organ on the body is not a simple “1 + 1 = 2” impact, but a serious impact on the whole body, and even life-threatening. Take the large blood vessel injury of the extremities as an example. This is one of the difficulties of trauma treatment, limb trunk vascular injury on the verge of amputation is often caused by high-energy trauma, combined with fractures, dislocations, nerve damage, bleeding, skin defects, and thoracic and abdominal cavity organs, etc., the handling of tricky, not only jeopardize the limb’s survival, and even endanger the patient’s life. Yet this systemic impact is often overlooked, said Director Zhao with slight helplessness. On the one hand, multiple traumas involving multiple parts and organs, due to the narrow knowledge of specialists, easy to be swayed by the surface or easy to observe injuries, only know the local injuries, but do not know the complications caused by the local, for closed injuries or visceral injuries in the short-term post-injury lack of obvious signs and symptoms, failing to focus on the management of multiple injuries according to the procedures. At present, most hospitals emergency surgery treatment mode, often in the diagnosis and treatment due to excessive consultation delays in the rescue time, but also easy to shift the blame. Multiple trauma treatment: do not miss the golden hour treatment time Surgical trauma patients from the accident to the operating table, within one hour is the best time for treatment. How to ensure that the patient in the “golden hour” within the effective treatment? In reality, many patients are forced to miss the “Golden Hour” due to overly specialized hospitals or the lack of comprehensive trauma treatment centers. On April 30, 2012, a male patient with left tibial plateau fracture, right femur comminuted fracture and vascular injuries, distal hemotransfusion poor 11 hours, from a county to a major hospital in Jinan, found that the right leg hemotransfusion is poor, amputation is recommended, the patient is reluctant, and contacted a number of hospitals, requesting limb preservation were politely refused, and then recommended to the Qianfoshan Hospital for treatment. Zhao Gang, director of the first time to carefully check the patient’s condition, at this time from the patient’s injury has been more than 11 hours. Eleven hours is a signal that the best treatment time has been missed. Theoretically speaking, limb ischemia is not more than 6 hours, limb reimplantation success rate will be much higher. Director Zhao said with feeling, in the many years of clinical treatment, often come across patients in a hurry, can not find the right treatment organization, thus delaying the best treatment of the golden time. When the best time for treatment is missed, even the highest technology may not be able to save the patient’s life. Fortunately, this time the patient came across Director Zhao. With the patient’s strong request for preservation, Director Zhao led the team to take a risk. Eventually he proved to be successful again. At this point, the race against time was the most critical step. Emergency preoperative preparation, vascular nerve exploration, intraoperative found that the patient’s left lower limb of the main vascular nerves have been severed, immediately repair the femoral artery; the patient presented low blood pressure, limb cold characteristics, found that the patient’s femur fracture comminution is very serious, and then internal fixation will take time, the patient has been unable to tolerate the pain, the anastomosis of the femoral artery, given a simple internal fixation, the use of external adjustable knee support fixation, and do Fascial compartment prophylactic dissection and decompression were performed. After successful limb preservation, internal fixation was repeated for further management. Postoperatively, the patient developed myoglobinuria, cardiac enzymes, aminotransferases, and bilirubin, which were markedly elevated and gradually became nearly normal after two weeks, and the outcome would have been self-evident if damage control surgery had not been performed. The emergency treatment of multiple injuries should reflect the concept that time is life, make diagnosis as quickly as possible while resuscitating and resisting shock, shorten the intermediate links, transfer quickly, start the first phase of surgery quickly, and do a good job of comprehensive postoperative treatment in order to improve the success rate of resuscitation. Director Zhao Gang precisely has advanced surgical concepts, with more than 20 years of orthopedic clinical practice, summed up more than 60 cases of successful limb preservation experience, for complex, multiple injuries, life-threatening and limb loss, the use of simple, feasible, effective and less damaging emergency life-saving surgery to deal with fatal trauma; further resuscitation and planning of staged surgical procedures to deal with non-fatal trauma treatment mode. The patient’s injured limb is preserved to avoid progressive depletion of physiologic potential; the time is gained for planning definitive surgery, in order to reflect the connotation of severe multiple injuries, emergency life-saving, staged surgery. Treatment of limb preservation: a complex systematic project Severe trauma of the extremities, is one of the more serious damage in multiple trauma, is a serious trauma belonging to the “near amputation injury”, mainly including near amputation of large blood vessel injuries, near amputation of the skin and soft tissue defects, near amputation of large bone defects, near amputation of the composite tissue defects, Complex trauma on the verge of amputation, disarticulation injury on the verge of amputation. The treatment of near-amputation injuries is mainly based on repair and reconstruction by non-amputation means. In the process of treating this kind of serious trauma, Director Zhao pointed out that this is a comprehensive and complex project, just like an athlete, he must be required to be an all-round sportsman, and each project must be required to achieve excellence, so that the state can be played to the best level. Director Zhao pointed out that the “near amputation injury” is facing a lot of problems, which is unimaginable to many people. Such as: the relationship between high-energy trauma and imminent amputation injury; the characteristics of different types of imminent amputation injury, injury analysis, treatment principles and repair measures; the guiding significance of damage control orthopaedic theory in the treatment of imminent amputation trauma; the treatment of complications and comorbidities, the diagnosis and treatment of special injury-causing factors resulting in imminent amputation injuries; the preservation of limbs in multiple injuries and compound injuries; the nursing and anesthesia of imminent amputation injuries and so on. How can we achieve effective treatment? Director Zhao said, on the one hand, need the intervention of microsurgical technology, especially the intervention of skillful flap repair technology, because this kind of trauma is often multiple injuries, multi-organ injuries, there is no fixed pattern of complex injuries, which requires the guidance of the theory of damage control. For this kind of serious trauma, it also needs the intervention of new treatment concepts and techniques, such as fixed biological principles, minimally invasive treatment techniques, VSD techniques, combined flap repair techniques, etc., which requires the skillful combination and application of advanced treatment concepts, methods and techniques, and moreover, it needs a high degree of sense of responsibility and hard-working and hard-working spirit of the health care personnel to complete the systematic project. Health is dependent on life. As an emergency surgeon, Zhao Gang, director of the usual work is very tired, but “is the bitter fun is also fun”. “When the patient puts the hope of life on us, we are carrying the weight of a life; when successfully treating a patient, we give him a continuation of life, that kind of joy and happiness fulfillment is self-evident.” It is Director Zhao who treats patients with kindness and love at all times, treating them as his own family members and even treating their pain as his own. He has cured countless patients who were on the verge of amputation by thinking about them wholeheartedly. At the same time, the reporter also learned that Director Zhao is actively building a green channel treatment model for multiple injuries, especially severe limb trauma. Further deepen and refine the “pre-hospital emergency – emergency surgery – EICU integrated emergency model”, diagnostic and therapeutic measures to strengthen the emergency measures, improve the level of life-saving treatment, such as compression hemostasis, relief of respiratory obstruction, relief of pericardial tamponade and so on, aimed at controlling the primary injury as soon as possible, and on the other hand, the director Zhao is actively creating a green channel treatment model for multiple injuries, especially severe limb trauma. The aim is to control the primary injury as soon as possible, and on the other hand, to take definitive medical intervention (including emergency surgery) as soon as possible in order to interrupt the chain of secondary injury, so that critically ill patients can turn from danger to safety and recover smoothly. The soon-to-be-established Shandong Multiple Injuries Treatment Center has a reasonable layout: the rescue room, ICU, medical and surgical emergency room, emergency surgery room, diagnostic imaging department (X-ray, CT room, MRI room and ultrasound room, laboratory, blood transfusion department, etc.) are located in the same floor of the same building, so that it can quickly and efficiently integrate the hospital’s medical resources within the golden resuscitation time, and the pre-hospital trauma first aid, the in-hospital trauma treatment and the nearest The 3 links of pre-hospital trauma emergency, in-hospital trauma treatment and near-term trauma intensive care treatment are interlocked to form a unified whole, realizing the integrated medical service model of pre-hospital, in-hospital and intensive care treatment, which significantly shortens the time and space for multiple injuries and patients to get definitive treatment, and facilitates the specialized treatment of patients. During the whole treatment process, the expert team and members of the emergency specialty group carry out the feedback mechanism of “assessment-decision-making-reassessment-decision-making”, which effectively reduces the death rate and disability rate of multiple injuries. (Zhang Chunming, Gao Wenchao)