Intermingled skin grafting: a valid transplantation method at low cost.

The almost forgotten method of intermingled skin grafting of allogeneic material with small autogeneic islets, once developed in the People's Republic of China, proves the feasibility of permanent healing of even extensive burn wounds, at low cost, and therefore an effective treatment possibility in poorer countries, as well as under conditions of a burn disaster. Intermingled skin grafting obtains a better elasticity of the reconditioned skin as elastic fibres of the allodermis survive, and this results in fewer contractures. From the cosmetic point of view the transplantation of autologous keratinocytes results in a better aesthetic homogeneous texture.

[Terrorists' target World Cup 2006: disaster medicine on the sidelines?! Aspects of hospital disaster planning]. / Terrorziel WM 2006: Katastrophenmedizin im Abseits?! Aspekte zur Krankenhauskatastrophenplanung.

Focussing on possible mass casualty situations during events such as the soccer world championship in 2006, the Professional Board of Surgeons in Germany and the German Society for Surgery canvassed surgeons-in-chief in the last quarter of 2003 concerning disaster plans for hospitals. The rate of returned questionnaires amounted to 26% covering the following areas of interest: plans-ready to use, known by the employees as well as by the rescue coordination center, performance of exercises, and concepts on decontamination and detoxification. Based on past numbers of casualties during soccer disasters, an excursus into details also includes a description of an approach to reduce the danger of bottleneck effects at doors. A preliminary concept based on the upcoming system for funding hospitals in Germany and including new partnerships is outlined, succeeded by some hopefully helpful hints for a web-based hospital disaster plan.

Ethics and triage.

A disaster is characterized by an imbalance between needs and supplies. In circumstances in which there occur mass casualties, it is not possible to provide care for all of the victims. Thus, it may be necessary to triage the casualties according to pre-established priorities. The performance of triage is associated with many ethical issues. Currently, no Europe-wide agreement on triage and ethics exists. One system based on a categorization into four groups is proposed. Triage should be avoided whenever possible, but, when it is required, there is an obligation to respect human rights and the humanitarian laws, especially with reference to the Geneva Convention of 1864 and the Universal Declaration of Human Rights of 1948. The condition of informed consent must be followed, even in mass casualty situations. Triage always must follow established medical criteria and cannot be based on any other principles. Triage implies constant re-evaluation of victims as conditions of the victims and of available resources change continuously. In order to facilitate international coordination and cooperation, a universal classification system must be adopted.

[Abu al-Qasim Az-Zahrawi--a great Arab surgeon] . / Abu al-Qasim Az-Zahrawi--veliki Arapski hirurg.

History is a witness of the great importance and influence of islamic science from the period of "Golden Age of Arabic Civilisation". A famous scientist said: "Science has no country, it is international; we all share in fruits of investigations of people from different traditions and all ages." There are many worldwide famous arabian scientists: El-Kindi, Er-Razi, Ibn Sina, El-Biruni, Ibn Hajsem, Ez-Zahravi, El-Farabi, Ibn Zuhr, Ibn Ruzd etc. These names, among several hundreds of arabian physicians, attribute "Golden Age" of islamic science. That period was characterised by movements, reprocessing of ideas. That reprocessing of ideas has gained the great minds together, and that process is continuous. That is why we have to be grateful to them. One of them, who is not enough famous within medical professionals, Az-Zahrawi, belong to the greatest surgeons in the arabian "golden age" period.

The German approach to emergency/disaster management.

Disaster control and disaster relief in Germany are public tasks. But the government has shifted the responsibility of the administration of these tasks to the 16 states, the so called "Lander", because the EFG is a federal republic. The same is valid for the civil defense and the civil protection in the case of military or international risks. The 16 states are also responsible for the legislation of rescue service, fire fighting service and disaster control (natural and technical disasters). Counties and district-free cities are responsible for the organisation of these services. The German system is based on the principle of subsidiary between official and private institutions. A lot of official and private relief organisations are responsible for the execution of disaster relief tasks. In Germany the following organisations exist: Official (GO): Technisches Hilfswerk (THW/Federal Technical Support Service), Feuerwehren (Fire Brigades/professionals and volunteers) Academie of Emergency Planning and Civil Defense Private (NGO): Arbeiter-Samariter-Bund Deutschland (ASB/Workers' Samaritan Association Germany), Deutsche Gesellschaft zur Rettung Schiffbruchiger (DGzRS, German Lifesaving Association), Deutsches Rotes Kreuz (DRK/German Red Cross), Johanniter-Unfall-Hilfe (JUH/St. John's Ambulance), Malteser Hilfsdienst (MEID/Maltese-Relief-Organisation). ASB, DRK, JUH and MHD are specialised in the field of rescue, medical and welfare services and medical disaster relief. 80% of the German rescue service and 95% of the German disaster medical relief are realised by these NGO's. NGO's and GO's employ more than 1.2 million volunteers and appr. 100,000 professionals. Rescue service is carried out by professionals, disaster relief by volunteers. The German constitution allows to call the federal army in case of disaster, to support the disaster relief organisations (for example: flood Oder River 1997, train-crash "ICE" 1998). In all counties and district free cities disaster control staffs are set up by the administration. During disaster relief operations a operational command is on site. Most of the counties and district free cities, medical executives, rescue staff executives along with fire executive officers are responsible for the medical rescue organisation. All emergency physicians and medical executives have attended special training or a 520 hours-training-course (Paramedics). All volunteers of the medical service in the disaster relief organisations are trained in separate special courses (90 hours). Over the last years, civil protection, disaster relief and rescue services in the FRG have been reorganised. In 1997, the civil protection was reformed by a new federal act. Disaster relief of the "Lander" is supported by Federal Government with about 9000 vehicles and a budget for training. Emergency physicians have to take part in a (80) eighty hours lasting course on emergency medicine from an interdisciplinary point of view; they are only allowed to do rescue missions after having proved basic experience in emergency medicine as well as having completed a (18) eighteen-months-postgraduate training period at least. Senior emergency physicians receive and additional (40) forty-hours-lasting theoretical and practical training-after three years practice in rescue services as a minimum. There are special training courses offered for Medical and Non-Medical Personal to cope with disaster situation by different institutions and organisations.

[Inguinal hernia: accident sequela?]. / Leistenbruch: Unfallfolge?

The evaluation of an inguinal hernia as a result of an accident has to be newly discussed because of new radiologic tools like US, CT and MRI. Therefore an injury of the abdominal wall after an adequate trauma has to be proved. This can also be achieved by radiology, in which signs of injury, as contusion and hematoma, can be detected. Moreover the histological signs of injury and bleeding, i.e. fibrinexudation, capillary granulation tissue, round cells, siderophages, fibrocytes and fibroblast proliferation must be proved.

[Legal aspects in early defibrillation by trained lay respondents]. / Rechtliche Aspekte bei der Frühdefibrillation durch geschulte Laienhelfer.

Ventricular fibrillation is the main reason for cardiac arrest. The probability for survival decreases by 10% every minute, therefore immediate resuscitation is necessary. Cardiopulmonary Resuscitation (CPR) by trained first responders is already established, when a doctor is not available. Today automated external defibrillators (AED) are available to first responders for an effective therapy of ventricular fibrillation. Thanks to the high reliability of today's automated external defibrillators they can be used by trained first responders without any legal reservations. If a defibrillator is available, a trained first responder is obliged to use it in an emergency.

Glossary of new concepts in disaster medicine: a supplement to Gunn's Multilingual Dictionary of Disaster Medicine.

The development of disaster medicine as a science is dependent on clear definitions of its language. This article proposes a set of definitions to supplement those currently accepted.

[Coordination of surgical relief concepts in the international community]. / Abstimmung chirurgischer Einsatzkonzepte in der internationalen Gemeinschaft.

Concerned by the increasing number and extent of disasters, the international community declared the period from 1990-2000 an international decade for natural disaster reduction (IDNDR). The "United Nations Disaster Relief Organisation" (UNDRO) was restructured into the "Department of Humanitarian Affairs" (DHA) to study ways and means of improving the co-ordination of international relief operations at the site of a disaster. This included the establishment of the "United Nations Disaster Assessment and Co-ordination Stand-by Team" (UNDAC) and the "On-site Operations Co-ordination Centre" (OSOCC) concept. Surgical relief teams had to implement new concepts regarding mission indication, guidelines, ethical code of conduct and measures of improved prevention, rehabilitation, reconstruction and sustainable development.

The flight from Rwanda in 1994: what were (are) the priorities?

EXTENT OF THE CATASTROPHE: More than 2 million refugees, 2-3 million displaced persons internally, thousands of unaccompanied children, and a total number of reported fatalities of 48,347 in Goma, Zaire. PRIORITIES FOR INTERNATIONAL RELIEF: International relief support started with coordination provided by the United Nations High Commissioner for Refugees (UNHCR). In the first phase, availability of potable water was the highest priority. Current priorities are to intensify repatriation of Rwandan refugees under conditions that will guarantee human rights and allow for dignified daily living. CONCLUSIONS: Education beginning at childhood, to overcome conflicts, social inequality, and overpopulation should be promoted by assisting governments, instead of pursuing policies aimed largely at forwarding their own national interests.

Evaluation of repatriation parameters: an analysis of patient data of the German Air Rescue.

We investigated the medical history of 1468 patients of the German Air Rescue with regard to indications and rules that are used for the repatriation of sick or injured people by aircraft from abroad. Some 25.5% of the flights were domestic flights within Germany, 40.9% from the European continent, and 33.6% from outside Europe: North Africa, North America, the Middle and the Far East. Of the patients, 46% were non-surgical and 54% were surgical cases. The majority (90.3%) of international cases were flown home in ambulance airplanes (Learjet, Merlin); the remaining 9.7% were scheduled flights. The rate of false alert was 7-10%. According to the National Advisory Committee for Aeronautics (NACA) classification, the majority of patients had moderate to serious illnesses. Some 33% of the patients were repatriated purely on medical grounds with an accompanying doctor. The indications of 66% of the patients were a mixture of medical and social components. Lists of points are available on the basis of catalogues of medical and social indications.

[Medical-social aspects of repatriation flights]. / Medizinisch-soziale Aspekte von Repatriierungsflügen.

The increase of journeys abroad has led to a continual rise of international flights repatriating ill or injured persons. These repatriations flights are carried out by rescue organisations such as the German Air Rescue Organisation. A survey of the patients transported has been made in respect with the patient collective. The following factors were taken into accounts: the severity of condition with regulation aids of the NACA (National Advisory Committee for Aeronautics), used by the American Army. Together with medical and social indications an additional parameter had be considered. A questionnaire is available to access the social indications. A neutral observer is recommended to protect the interest of the patient, insurance company and the rescue organisation.

Spontaneous gas-forming bacterial myonecrosis caused by group B streptococci and peptostreptococci.

We present the case of a patient who spontaneously developed a severe gas-forming infection involving the voluntary muscles of both thighs. The organisms responsible were group B beta-haemolytic streptococci together with peptostreptococci. Following surgical and medical treatment, the patient fully recovered. No predisposing factors, in particular no disease causing immunocompromise, could be identified.

[Thermal skin and bone necrosis following injury with an ultrasound bonding machine]. / Thermische Haut- und Knochennekrose als Folge einer Ultraschallschweissverletzung.

The article reports on a case of cutaneous gangrene and osteonecrosis resulting from thermal injuries inflicted by a high-frequency ultrasonic bonding machine used, for example, in the bonding of plastics. If high-frequency ultrasonic waves come in direct contact with the skin, a fraction of a second will suffice to produce heat and subsequent destruction even of deep tissue layers. The heat is produced by the absorption of mechanical vibrations, by reflection of these vibrations, and by surface friction. The heat, therefore, not only penetrates into the tissue, but is also generated in the deep tissue layers. The extent of the necrosis depends on the depth of penetration of the high-frequency ultrasonic waves. As with electrical burns, the necrotic tissue is excised with a margin of normal tissue and then covered by a skin graft.

[External fixation of wood as an example of an adapted technic]. / Fixateur externe aus Holz als Beispiel angepasster Technik.

Logistic reasons gave rise to construction, production and application of an external fixation made of the wood of the rubber-tree (ficus elastica) during the treatment of Cambodian war-injured patients at the field hospital of Khao I Dang. Round pieces of wood 1.5 cm respectively 2 cm in diameter, with drill-holes (diameter 3.2 mm) for the "Steinmann"-nails were planed from well-seasoned planks of the Jang-tree. For the treatment of 25 open fractures - the wooden fixation proved to be the best solution.

[Measurement of compressive forces at the external fixator by means of a dynamometer to prevent subsequent osteosynthesis after bone fracture (author's transl)]. / Druckmessungen mit dem Dynamometer am Fixateur externe zur Vermeidung von Nachfolgeosteosynthesen.

Bone fractures treated with an external fixator tend to heal more slowly than with an internal fixator, since the tension of the fixator gradually relaxes and this decrease in pressure is not counteracted on any way. A dynamometer makes possible an exact measurement of effective compressive forces and an adjustment of the tension of the fixator. A special feature of the apparatus is an elastic metal ring. The apparatus is mounted on the free ends of both tubes of the fixator for measuring and adjusting the tension. This should be done once a week. Supported fractures are put under an axial compression of 50 kp. In the case of comminuted and defect fractures, an axial compression of 5 kp should be begun after 5 weeks, and this dosage should be increased every week.