Letters to the Editor 469

doi:10.1016/j.injury.2005.12.030

AUTHOR’S REPLY

Surgical and psychosocial outcomes in the ruralinjured–—A follow-up study of the 2001 earth-quake victims

Beyond good intentions

I thank Mr. Arvind Mohan for his comments andregret throwing a wet towel on the volunteeringspirit of visiting orthopaedic surgeons, like him.However, that was precisely the purpose of thearticle. We chose to publish our findings in theINJURY journal, since a majority of the readershipconsists of orthopaedic surgeons and caregivers ofthe injured. Though the article does not reflect thepopular sentiment, it addresses our great concernabout standards of care in vulnerable populations ofthe developing world. While ‘‘Do no harm’’ is everysurgeons’ aim, it is usually, wisdom in retrospect.Unless, we follow-up our cases, it is hard to knowwhether good or harm has been done. Unfortu-nately, nothing spoils the good results of an opera-tion, as quickly as a follow-up! We have presented inthis follow-up study, our ‘‘own’’ shortcomings,infection rates, missed injuries and amputationrates. Putting seniority aside, we decided to betransparent about our mistakes to do a better jobin times to come. Surprisingly, Mr. Arvind Mohanseeks to justify the compromised care rendered tothe disaster victims, beginning with inclementweather. Honestly, no visitor flying out of the Englishwinter into the wonderful temperate Januaryweather of Gujarat, can ever call it extreme!Further, he complains that the government machin-ery, after the earthquake, was in disarray makingclinical management difficult. But that indeed, isthe basic definition of ‘disaster’–—that which over-whelms the normal healthcare system.

The nature of injuries following earthquakes hasbeen well documented in the literature and themajority are open injuries.2,3,5 However, there areno follow-up outcome studies on disaster-relatedinjuries, available for comparison. Therefore, inour article, we have scrupulously avoided makingqualitative judgements about percentages (beinghigh or low) of non-union, amputations or missedinjuries. But those of us, who stayed back to dressthe postoperative wounds, after the volunteeringsurgeons had left, bear testimony to the spoils ofsurgery. While ‘‘fixation is fun’’–—to borrowApley’s famous editorial in the Journal of Bone andJoint Surgery,1 usually the bad results of operative

DOI of original article: 10.1016/j.injury.2005.12.031.

treatment are worse than the bad results of non-operative treatment in the developing world set-ting.4 These are basic lessons in disaster medicine,which is now a speciality and it goes beyondATLS training. The sphere project (http://www.sphereproject.org/) is a good reference, whichemphasises ‘‘quality and accountability’’ in complexhumanitarian emergencies for healthcare and disas-ter workers.

Lastly, we share Mohan’s concern about us nothaving studied PTSD in healthcare providers. We,indeed would have studied them, if they did notvanish so quickly in the postoperative period.

References

1. Apley AG, Rowley DI. Fixation is fun. J Bone Joint Surg Br1992;74(4):485—6.

2. Armenian HK, Melkonian A, Noji EK, Hovanesian AP. Deaths andinjuries due to the earthquake in Armenia: a cohort approach.Int J Epidemiol 1997;26:806—13.

3. Kuwagata Y, Oda J, Tanaka H, et al. Analysis of 2702 trauma-tized patients in the 1995 Hanshin—Awaji earthquake. JTrauma 1997;43:427—32.

4. Sethi PK. Orthopaedics in an unjust world. Ind J Med Ethics1999;7(3):86—90.

5. Shoaf KI, Sareen HR, Nguyen LH, Bourque LB. Injuries as aresult of California earthquakes in the past decade. Disasters1998;22:218—35.

Nobhojit RoyDepartment of Surgery, BARC Hospital,Anushaktinagar, Mumbai 400094, India

E-mail address: nobsroy@yahoo.com

LETTER TO THE EDITOR

When things do not go right

Sir,

We read with interest your editorial entitled ‘‘Whenthings do not go right’’.2 We agree that we must allstrive to minimise avoidable complications in ourpractice. To do this we must identify complicationsthat occur on a regular basis and use the audit cycleto ensure improvements are being made. This, how-ever, relies on accurate data collection and quality.It has been demonstrated that much of the datacurrently collected in the NHS is inaccurate.1 Wenote too that standard definitions are not availablefor many common complications.

470 Letters to the Editor

doi:10.1016/j.injury.2005.01.027

Our hospital previously reported what constitutesa reasonable complication rate; 10% in orthopaedicpractice.3 Our hospital concluded that a complica-tion rate lower than 10% advertises incompleteaudit, not clinical excellence. A higher complicationrate may therefore be demonstrated in institutionswith good data collection.

We suggest that in the presence of good qualitydata and standard definitions, orthopaedic surgeonsought to aim for a complication rate of no less than10% as a baseline for the audit cycle.

References

1. Keong N. Pressure sores following elective total hip arthro-plasty: pitfalls of misinterpretation. Ann R Coll Surg Engl2004;86(3):174—6.

2. Krikler SJ. When things don’t go right. Injury 2005;36:577—8.3. Ricketts D, PattersonM, NeweyM, Hitchin D, Fowler S. Markers

of data quality in computer audit: themanchester orthopaedicdatabase. Ann R Coll Surg Engl 1993;75:393—6.

A.P. Hudd*D.M. Ricketts

The Princess Royal Hospital, Haywards Heath, UK

*Corresponding author. Tel.: +44 01444 441881;fax: +44 01444 441879

E-mail address: alastair.hud@bsuh.nhs.uk(A.P.Hudd)

12 May 2005

doi:10.1016/j.injury.2006.01.017

AUTHOR’S REPLY

When things don’t go right

Thank you for your response to my editorial.1 Iquite agree, the quality of data is vital and thestandard of data collection in the NHS in my experi-ence is, at best, of doubtful reliability. The inac-curacy of NHS data on hip fractures has beenstudied with reference to league tables and pre-sented at a British Orthopaedic Association meet-ing.2 Clearly, we must all strive to produce the bestfigures, by which I mean both the best quality dataand the best outcomes in reality. On this basis, I amnot sure that aiming for a specific complicationrate is desirable. If my complication rate is really10% (and I do not have good enough data to knowwhat it really is), I would aim to reduce it. To

paraphrase a well-known saying, the key is to avoidthe avoidable complications, accept the unavoid-able ones and have the information to truly recog-nise the incidence of both.

References

1. Krikler SJ. When things don’t go right. Injury 2005;30:577—8.2. Moran CG, Hunter JB. Dr Foster and the hip fracture league

table. Fact orfiction? J BoneJoint Surg [Br] 2003;85-B(Suppl. II):173.

Steve KriklerInjury Editorial Office, Elsevier, The Boulevard,

Langford Lane, Kidlington OX5 1GB, UK

E-mail address: steve.krikler@ntlworld.comeditor@injuryjournal.com

LETTER TO THE EDITOR

A novel method of applying split cast

Dear Editor,

I read with great interest the technical note‘‘A novel method of applying a split cast’’ by Belthuret al.1 I agree with the authors that a slit plaster castis better than a complete cast or backslab.

However, I would like to express some of myconcerns on the technique as detailed below:

1. Split casts are traditionally split down to theskin.2 However, the authors here have describeda technique which splits only the plaster. Thecutting track may be left over the skin directlyand pulled out at the end alternatively. Using twopieces which meet in front of the ankle in theillustrated case may make this easier.

2. The authors have applied tape around the leg tohold the cutting track down. Will the tape nothold on to the cutting track even after the plasteris split and prevent it from separating? Placingthe cutting track upside down, with flat endfacing away from skin, may be a solution for thisproblem. Placing the track as authors describe itmay cause the plaster spreader to engage thetrack, thus making it difficult to spread as well.

In the postoperative period backslabs have beenproven to be more appropriate after internal fixa-