With fall than in the suburban emergency rooms Muscovites, why do we need three-tier system of trauma centers and is possible in the district hospital the world-class medical care, told Mednovosti head of the trauma center of sergiyevo-Posadsky district hospital M. D. Andrey Pavlov.
Andrei I. surgeons in small towns, unlike their counterparts in the Central hospitals, we have to be generalists and to provide almost any assistance. Good or bad?
– It forced. And then, these wagons remained not so much. It is the people of the old school, and not necessarily in the regions. Such experts, for example, head office in CITO, Botkin hospital, the Sklifosovsky Institute. And the younger generation is more specialised. Today is tough enough differentiation even within the same specialty, and, in my opinion, rightly so. There are branches, which deal only with arthroscopic techniques or prosthetic hip and knee, performing these operations on the stream.
But in small towns where this is not possible, doctors have to be experts in related disciplines. And not always it is beneficial to patients. Thus, many trauma centers still engaged in the treatment of burns, which, in General, although it is a trauma, but requires a completely different approach. Moreover, burn patients are always initially infected. And their treatment on the basis of trauma care, where there are “clean” operation on the skeletal system, the joints, actually, just harmful.
And where is the exit?
– Out in building a three-tiered system of trauma centers. This is a very correct idea, which came to us and to Europe from USA. And in the Moscow region the system is already debugged. Trauma centers of the third level work in small hospitals. The second level, like ours, carries the heavy load and provide maximum assistance. In the centers of the first level, where the whole area is just five, there is a separate neurosurgical, vascular Department, where if it is impossible to cope with pathology, we transport patients. Often it concerns patients with severe concomitant injury suffered in an accident, children. Lately helicopters sanaviatsii have taken five children with severe cranial trauma.
Another very important thing is that today, traumatology, as well as all medicine, standartisied. There should not be confusion and vacillation, clinical guidelines are developed by national and world associations of orthopaedic trauma, constantly updated, and should be clearly and correctly perform. And the moment of creativity, which of course is present in our work, occurs when the patient is stable, and we plan the next phase of operation.
What opportunities are there today trauma the second level?
Hospital, having the ability to provide virtually the entire spectrum of trauma care, in the Moscow region is not much. But we are among their number. We own all minimally invasive techniques performed total joint replacement, osteosintez (the fixation of bones of all segments), the so-called submersible operations on the bones of the pelvis is like a mount Olympus in traumatology. Treating patients with combined injury with burn injury. Performed on-site fixation of the spine – we have a neurosurgeon and, if necessary, invite experts from the neurosurgical center of the city of Dolgoprudny. In addition, we are the only clinic in the Moscow region, in the state of which has a hand surgeon who owns, including technologies of osteosynthesis of small bones, hand, forearm.
One of the branches of our Center is engaged in treatment of patients of elderly and senile age with damage to the proximal femur (the neck of the femur, fractures in trochanteric region and the intertrochanteric fractures). This is a huge problem. After all, for example, when fracture of the tibia or ankle, you can put a cast on, the wreckage stopped moving, and the pain subsides. As a person with a hip fracture to carry out the immobilization impossible. In other people’s walls with constant pain impulses in an older person developing traumatic disease that leads to mental disorders – it ceases to recognize relatives, excited.
Of course, we use sedative therapy, but the main thing is the fastest possible stabilization of the fracture, because as soon as a person realizes that he can sit, he comes alive. Last year we performed about 260 operations such surgeries for patients ranging in age from 72 to 95 years. Now in office is the grandmother born in 1923, tomorrow we with God’s help, will remove her stitches and send him home.
Earlier on this could not even dream of.
Yes. More recently, such a fracture for elderly patient had a verdict. Moreover, in many places still, and it is also a huge “minus” of small towns. Today, few people deliberately doing it. These are very complex patients that require rapid and adequate assistance, minimally invasive techniques. And in addition to direct treatment, it is necessary to solve many organizational issues. We have internal regulatory orders that have helped us to develop colleagues from CITO. Of course, we are still a long way, CITO, in these patients operate within a day or two of receipt, but we still try to do it in five days. We accept patients from neighboring areas and even from other regions, where people bring their old, learning that there is a place where they can help.
And what forces cope with the workload?
– We have two trauma unit headed by a very experienced heads, two doctors and two deturant in each division, plus the hand surgeon. Surgical Department, which is responsible for complications in severe concomitant injury involving rupture of the liver, spleen, damage to lung tissue. And, of course, in our submission is the primary line of defense – the emergency room, through which in summer a shift takes place up to 120 patients.
Usually, injured patients more in the winter when the roads are icy.
– We have now all gone seasonality, both offices are always filled. In winter it is mainly the inhabitants of the city and district. And in the summer they added guests to the country Muscovites who believe that they are excellent specialists in working with cutting tools. We receive a large number of severed fingers, severed tendons. In such cases, primary care should be provided as soon as possible is very important in trauma of the hand.
It is still very important and relevant equipment.
– Equipment always want more and better. We have a fairly worn-out equipment, but it is still working. And most importantly, in the regional Ministry of health has considered the application from our hospital to equip the trauma center. We are talking about additional tools, equipment neurosurgery microscope, which can be separated reimplantation of limbs. In addition, the application is stand for minimally invasive arthroscopic operations on the knee joint. As soon as we have them, we teach these techniques to our physicians and patients do not have to drive for such assistance to Moscow.
Technologies are improving very quickly today. But we should not forget about what we call primary education lays the basic principles of traumatology. If you’re accustomed to properly examine the patient, understand how to conduct preoperative planning, able to work with the results of radiological diagnosis, Yes, good equipment is nice to help. And if not, then, as they say, technology in the hands of the savage – just a pile of metal. And, of course, the doctor should never stop learning. Constantly appears something new on the market (don’t really like that word, but without it anywhere) medical products, new methods of treatment. And if you don’t constantly evolve, to attend major symposia and seminars, including foreign ones, then very quickly fall behind.
In the suburbs every district hospital should work as an emergency. Does it always happen?
– Turns. Butof course, the trauma of high level can only exist in a large General hospital. When the Ambulance reports from the scene of an accident of severe concomitant trauma in the emergency room the patient was immediately met by the emergency physician and trauma surgeon. He was then driven green corridor immediately to the intensive care unit, where they begin anti-shock activity. Or, if the condition allows, in x-ray diagnostic Department with CT scan of the whole body, which immediately reveals the nature of all injuries.
If a person has a broken ribs with damage to the lung tissue, pneumothorax, hemothorax, after resuscitation he was transferred to the surgical ward. To cope with the surgical pathology, return it to us. Patients with this severe complication like thromboembolism immediately get into cardioreanimation. But as soon as we allow the doctors, we’re operating on such patients, stabilize fractures by external fixation devices So, thank God, in the treatment of severe combined injuries to our hospital for the second year is the so-called green zone – that is, a small mortality.
Many people believe that trauma is not the specialist that is accessed for screening. Not identifying diseases of the musculoskeletal apparatus and the medical examinations.
– Consultation of the traumatologist is actually needed by all. For example, simply watching as a man walks in front of me, I can diagnose his pathology of the hip or scoliotic deformation is what was originally taught in a good medical school. Often people with pain in the hip joint indefinitely to go to a neurologist and treated on the existing wire is not lumbalgia, and it turns out that they have a serious injury of the hip hip joint.
We have a huge number of young women are living without knowing it, with primary dysplasia, and after birth, begin to experience severe pain in the hip joints. And when we see their pictures, we understand that the disease was for a long time, perhaps even this congenital dysplasia, and childbirth became the trigger to further destruction of the joint. So, if over time consultation of traumatologist will be included in the examination, will be good.
And what the surgeon can help his patient in a planned manner?
– Planned trauma is always Orthopaedics, the treatment of congenital abnormalities, some of the consequences of injuries or diseases that develop many years, depriving people of the opportunity to move. For example, in case of arthrosis of the knee joint – a prosthesis according to the system of VMP. Now we are sending patients to MONICA, but I think that will soon get the license for the PMF, so that people could get this assistance at home. And while patients are waiting for quotas or are not configured to dentures, they can help conservative treatment – anesthetized therapy, intra-articular blockade, physiotherapy.
Trauma is a constant pain. Now in our country, changes related to anesthesia. And you probably easier to work with?
– The person should not experience pain after the surgery. The pain can lead to anything, including acute coronary syndrome. And “a little patience” is very bad advice. But I never cease to amaze. When we are using young people after the termination of the spinal anesthesia to numb they ask their every hour, and we naturally do this because it is part of standard postoperative management of patients. But 90-year-old women themselves may not ask for pain relief – so they are not spoiled and accustomed all his life to endure.
What is the most difficult in working with patients?
– I find it easier to answer that the easiest. For me it’s handling, because most in life I love to operate, and when I get to the operating room, there I home. Everything else is more difficult. From preoperative planning, the preparation of some documentation of conversation with relatives of patients.
There are times when patients and their relatives do not want to see?
– No, I did not happen. I grew up in a medical family and was not for any other specialty. And during infancy, as a doctor, I had such teachers who taught that we must endure: people are different, but it affected people who come to us with their grief, and we just have to help them. And then many of our patients are so interested in up and around that, seeing this response, I want to work harder. Sometimes you walk past the house and you sick calls: “Andrey Igorevich, you promised me to look like.”
You know, I’m a native Muscovite, and a large part of his professional career he has worked in the Moscow healthcare system. But, I am very happy that he was in Sergiev Posad. Live here are amazing people, and they are much easier to work than residents of the capital – and by patients and their relatives.