State of the art 1949 – Birmingham Accident Hospital

A summary produced by Gissane

BAH Surgical Principles (1949) – Shock

Treatment of shock based on early accurate diagnosis of the injury or injuries requiring urgent surgical treatment
Aim to resuscitate patient until fit state to undergo surgery
To amend the optimal time for operative treatment and how much the patient can safely tolerate
To amend priorities in operative treatment
An experienced surgeon is essential

Closure of open wounds by various skin grafting techniques after careful surgical cleansing is the only way to prevent wound infection. It is also the method which gives adequate skin cover and the maximum function in the quickest time
Colebrook has proved beyond all doubt that the longer a wound remains open the more certain it is to become infected. Vicious circle of: “the wound will not heal because it is infected, and it remains infected because it will not heal”

Treatment of shock and the prevention of shock by the controlled infusion of plasma
Prevention of infection of large wounds by a most careful dressing technique in air-conditioned stations
The controlled use of local (topical) penicillin and the sulphonamides against infection
The urgency of wound cover by skin
The efficiency of early splintage in position of function
Advising the general nutrition needs of the patient
The BAH approach produced the best figures in the UK
In the last 270 burned and scalded patients requiring inpatient treatment the overall mortality was 17%.
In 790 severe burns in all ages the mortality was 4.7%
The aseptic room in which the patients had their burnt areas dressed at the Acci was unique – throughout the time of dressing a constant stream of filtered fresh air was directed into the room by an electric fan, while open culture-plates were exposed at different parts of the room so that, if any pathological germ grew on any of the plates it would be possible to trace it to its source by bacteriological examination of every person who was known to be in the room at the time of dressing the wound.

BAH adopted the principle of treatment from Sterling Burnell
Treatment of severe injuries must whilst in a fresh state, be treated by experienced staff well versed in tendon, bone, nerve and skin injury
Careful amount of what can and cannot be done in the first surgery is essential
Closed hand infection invariably prevents themselves for treatment at an early stage as either pulp or tendon sheath infection, early appropriate treatment is mandatory
For tendon sheath infection, adequate systemic penicillin and early accurate but minimal surgical drainage gave first class functional results with over 90% of patients achieving full functional recovery

Largest single group of injuries from accidents
Immediate treatment calls for high degree of manipulative and sometimes operative staff. The early surgical treatment should present no real difficulty to the experienced practitioner
It is in the aftercare of these injuries that special facilities are essential for example, the close supervision of a limb immobilised in plaster, the early continuous and well supervised programme of rehabilitation to prevent muscle wasting and the development of preventable deformity
The early assessment should be with the objective of achieving optimal functional recovery. This may include open surgery, bone grafting, arthrodesis or sometimes arthroplasty
Most severe accidents produce patients with multiple injuries – usually fractures and other injuries. Especially relevant are injuries to the brain, the thoracic contents, the abdomen and pelvic viscera
Visceral injurie less than 1% of total admissions but they are important group on account of severity
Head and Chest Injuries are the injury that produce real problems in diagnosis and treatment. The treatment of the patient, as a whole, remains the most important consideration

Accident patients admitted with various grades of severity. They can be segregated in the admission department
Fresh accidents presented on average at a rate of 1 per every 5 miles. The patient can be triaged into stretcher cases and those walkers with obvious severely injured
Once patients determined the patients follow the allocated pathway
BAH felt very strongly that those very seriously injured patients should be admitted to a shock room situated near the entrance to the hospital
The outpatient and rehabilitation department must be built so there is no unnecessary delay
There must be sufficient numbers of experienced surgical and auxiliary medical staff. In the final assessment the efficiency of a hospital is dependent on its surgical staff

The Birmingham Experience has convinced me of its rightness – Gissane
Patients have found their way to the Acci in ever increasing numbers
Also, its full surgical and research staff elected on the cessation of war are as keen and as convinced of its rightness as Gissane
The hospital is receiving more and more trauma victims from neighbouring casualty and fracture departments

Gissane felt that staff in smaller hospitals could be trained in Central Accident Hospitals
The tempo of work is in a central accident hospital is one of a high pressure with the turnover of large numbers of patients. Immediate careful assessment of each patient is of vital importance. Mortality in the first 24 hours cannot usually be rectified
The demand of knowledge of certain aspects of many specialties, in order to plan long term possibility in repair, as well as ability to think fast
Gissane believed in the concept of the “Surgery of Function”
To optimise to a maximum surgical outcome
To achieve this Gissane believed in close and friendly links must be established with elective orthopaedics, plastics, maxillofacial surgery, peripheral nerve surgery for long term repair requiring the finest development in surgical craftsmanship