Pakistan Earthquake: Experiences of a Multidisciplinary Surgical Team

Abstract

Four weeks after the earthquake in Kashmir, Pakistan, multidisciplinary surgical teams were organized within the United Kingdom to help treat disaster victims who had been transferred to Rawalpindi. The work of these teams between 05-17 November 2005 is reviewed, and experiences and lessons learned are presented.
Two self-sufficient teams consisting of orthopedic, plastic surgical, anesthetic, and theatre staff were deployed consecutively over a two-week period. A trauma unit was set up in a donated ward within a private ophthalmological hospital in Rawalpindi.
Seventy-eight patients with a mean age of 23 years were treated: more than half (40) were <16 years of age. Fifty-two patients only had lower limb injuries, 18 upper limb injuries, and eight combined lower and upper limb. The most common types of injuries were: (1) tibial fractures (n=24), with the majority being open grade 3B injuries (n=22); (2) femoral fractures (n=11); and (3) forearm fractures (n=9). Almost half (n=34) of the fractures were open injuries requiring soft tissue cover. Over 12 days, 293 operations were performed (average 24.4 per day). A total of 202 examinations under anesthesia, washouts, and debridements were performed. The majority of wounds required multiple washouts prior to definitive procedures. Thirty-four definitive orthopedic procedures (fixations) and 57 definitive plastic procedures were performed. Definitive orthopedic procedures included 15 circular frame fixations of long bones, nine of which required acute shortening and five open reduction and internal fixation of long bones. Definitive plastic procedures included 21 skin grafts, four amputations, 11 revisions of amputations, 20 regional flaps, and one free flap.
A joint ortho-plastic approach was key to the treatment of the spectrum of injuries encountered. Only four patients required fresh amputations. Twenty patients may have required amputation without the use of ring fixators and soft tissue reconstruction. Having self-sufficient teams along with their own equipment and supplies also was mandatory in order not to put further demand on already scarce resources. However, mobilizing such teams logistically was difficult, and therefore, an organization consisting of willing volunteers for future efforts has been established.

Full text

July – August 2010 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine
CASE STUDY
Abstract
Introduction: Four weeks after the earthquake in Kashmir, Pakistan, multi-
disciplinary surgical teams were organized within the United Kingdom to
help treat disaster victims who had been transferred to Rawalpindi. The work
of these teams between 05–17 November 2005 is reviewed, and experiences
and lessons learned are presented.
Methods: Two self-sufficient teams consisting of orthopedic, plastic surgical,
anesthetic, and theatre staff were deployed consecutively over a two-week
period. A trauma unit was set up in a donated ward within a private ophthal-
mological hospital in Rawalpindi.
Results: Seventy-eight patients with a mean age of 23 years were treated:
more than half (40) were <16 years of age. Fifty-two patients only had lower
limb injuries, 18 upper limb injuries, and eight combined lower and upper
limb. The most common types of injuries were: (1) tibial fractures (n = 24),
with the majority being open grade 3B injuries (n = 22); (2) femoral fractures
(n = 11); and (3) forearm fractures (n = 9). Almost half (n = 34) of the frac-
tures were open injuries requiring soft tissue cover.
Over 12 days, 293 operations were performed (average 24.4 per day). A
total of 202 examinations under anesthesia, washouts, and debridements were
performed. The majority of wounds required multiple washouts prior to
definitive procedures. Thirty-four definitive orthopedic procedures (fixations)
and 57 definitive plastic procedures were performed. Definitive orthopedic
procedures included 15 circular frame fixations of long bones, nine of which
required acute shortening and five open reduction and internal fixation of
long bones. Definitive plastic procedures included 21 skin grafts, four ampu-
tations, 11 revisions of amputations, 20 regional flaps, and one free flap.
Conclusions: A joint ortho-plastic approach was key to the treatment of the
spectrum of injuries encountered. Only four patients required fresh amputa-
tions. Twenty patients may have required amputation without the use of ring
fixators and soft tissue reconstruction. Having self-sufficient teams along with
their own equipment and supplies also was mandatory in order not to put fur-
ther demand on already scarce resources. However, mobilizing such teams
logistically was difficult, and therefore, an organization consisting of willing
volunteers for future efforts has been established.
Rajpura A, Boutros I, Khan T, Khan SA: Pakistan earthquake: Experiences of
a multidisciplinary surgical team. Prehosp Disaster Med 2010;25(4):361–367.
Department of Orthopedics, Hope Hospital,
Salford, UK
Correspondence:
Mr. Asim Rajpura
6 Manthorpe Ave.
Worsley
Greater Manchester UK
M28 2AZ
E-mail: asimrajpura@gmail.com
No benefits in any form have been received or will
be received from a commercial party or individual
related directly or indirectly to the subject of this
article.
Keywords: earthquake; Ilizarov; Kashmir;
limb reconstruction; multidisciplinary;
orthopedic; Pakistan; plastic surgery
Abbreviations:
ORIF = open reduction and internal fixation
Received: 12 August 2009
Accepted: 28 September 2009
Revised: 05 October 2009
Web publication: 26 July 2010
Pakistan Earthquake: Experiences of a
Multidisciplinary Surgical Team
Asim Rajpura, MRCS; Ihab Boutros, MRCS; Tahir Khan, FRCS (T&O);
Sohail Ali Khan, FRCS (T&O)
Introduction
On 08 October 2005, an earthquake measuring 7.6 on the Richter scale struck
the northern areas of Pakistan and India.1The epicenter was located approxi-
mately 19 km northeast of Muzaffarabad in Pakistan. The North West Frontier
Province of Pakistan and Pakistani-administered Kashmir were the most severe-
ly affected areas. Relief agency data estimate that >73,000 lives were lost, 128,000
individuals were injured, and >3.5 million people were left homeless.2The earth-
quake decimated the local infrastructure, with more than 50% of the healthcare
facilities in the area being destroyed, and a further 25% damaged.

Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol. 25, No. 4
362 Pakistan Earthquake
ing room, and an office. A separate dressing clinic also was set
up for changes of dressings that did not require anesthesia.
Local anesthetic and scrub staff were available, but staff from
the team carried out all operating. A plastic surgical consultant
from New Zealand also joined the team for the second week.
Results
Patient Demographics
The mean value for the ages was 23 years (range: 6
months–80 years). More than half (n = 40) were <16 years,
with 10 patients <5 years. Only eight patients were >60
years old. The age and sex distribution of the patients are in
Figure 1. Approximately 60% were female.
Nineteen patients had minor injuries that did not
require further management, and therefore, were dis-
charged. These included ankle and upper limb fractures
amenable to conservative management with casts. One
patient needed transfer to a pediatric intensive care unit due
to severe sepsis from extensive muscle necrosis.
Two-thirds of the injuries encountered were lower limb
(n = 52), 18 upper limb, and eight combined upper and lower
limb (Figure 2). The most common injury encountered were
tibial fractures (n = 24), of which 92% were Gustillo-
Anderson grade IIIb (Figure 3). The majority were immobi-
lized in plaster, while others had monolateral external fixators
applied. None had received definitive orthopedic fixation or
plastic surgical treatment to provide soft tissue cover. All
open fractures required multiple washouts and debridement
due to infection prior to receiving definitive treatment.
Femoral fractures were the second most common injury
encountered, with 64% in children. The four adult femoral
fractures had been managed by open reduction and internal
fixation (ORIF), three using unlocked Kunscher nails and
one with dynamic compression plating. The two pediatric
cases who received internal fixation were treated with small
fragment dynamic compression plating. These procedures
were carried out previously in field hospitals, and therefore,
exact details of treatment and management were not avail-
able. Two of the fixations were infected. The remaining
pediatric femoral fractures had been immobilized in hip
spicas. The position of the fractures in hip spicas was not
perfect, but accepted at this stage, as callus was visible.
Open osteoclasis would have been ideally required, but
remodeling was expected.
The most common upper limb injuries seen were fore-
arm fractures, followed by humeral and hand injuries. The
majority of these (65%) were closed fractures. Examples of
open injuries seen included an open Galeazzi fracture, open
supracondylar fractures, open mid-shaft humeral and
radius/ulna fractures, and open carpal disruptions.
Twelve patients only suffered soft tissue injuries.
Examples included an 8-year-old child with truncal burns
requiring split skin grafting, and patients with sacral pres-
sure sores and lower limb soft tissue defects.
Overall, almost half (n = 34) of the fractures seen were
open injuries that required soft tissue cover.
Procedures Performed
A total of 293 procedures were carried out over 12 operat-
ing days (average 24.4 per day). The setup of the operating
The scale of the disaster overwhelmed local healthcare
systems. Several international agencies such as the
International Committee of the Red Cross set up field hos-
pitals in the affected areas to deal with the immediate after-
math of the earthquake.
Four weeks after the earthquake, a team of British
orthopedic and plastic surgeons was assembled to assist
with the aid effort. The aim was to attempt to limit mor-
bidity and mortality from the complications of the injuries
in the survivors, as demonstrated by the third peak in the
trimodal distribution of death post-major injury.3,4 To date,
studies mainly have described the treatment of patients in
the immediate aftermath of the earthquake.5–10 The expe-
riences from this expedition dealing with the delayed com-
plications of the injuries and highlight lessons learned that
could be applied to future efforts are reported.
Methods
Team Composition
The nature of the injuries being reported necessitated a
joint ortho-plastic surgical approach. Thus, two teams com-
prised of two consultant orthopedic surgeons, two senior
plastic surgery registrars, two consultant anaesthetists, one
junior surgical trainee, two scrub nurses, and one operating
department assistant were formed. The teams were
deployed for two consecutive weeks starting 05 November
2005. Orthopedic staff chosen for the task had specialist
experience in limb reconstruction. The plastic surgeons also
were experienced in the management of large soft tissue
defects. The teams were formed of staff from northwestern
England. They were not part of any coordinated national or
international effort.
With the help of a non-governmental organization, the
Pakistan Red Crescent Society, and UK-based charity
Islamic Help, a makeshift trauma ward and theatre complex
had been setup within a privately owned ophthomoligcal
hospital in Rawalpindi, Al Shifa. Basic x-ray and patholo-
gy services were available on-site and a mobile theatre x-ray
image intensifier was provided by the charitable organiza-
tion. This was the group’s base during the two-week mis-
sion. The complex orthopedic, plastic, and anesthetic
equipment was donated and/or borrowed from the respec-
tive base hospitals in the UK.
The patient population consisted of injured survivors
who were transported to the capital from areas near the
epicenter. A local sports field was used as a reception facil-
ity for these patients. From there, local healthcare teams
triaged the patients and 97 patients with limb injuries were
sent to the trauma ward. All patients had received basic care
in field hospitals set-up in the disaster area.
Documentation regarding their injuries and treatment
to date not always was available. Initial tasks included triage
and creating basic case records and a database of patients.
Patients and injuries were photographed and assigned case
note numbers to aid identification and team handover.
All operating was carried out in a theatre complex situated
within the makeshift trauma ward. This consisted of an “open
plan theatre suite” with three operating tables, each separated
by Perspex dividers allowing concurrent operations to take
place, a recovery room, instrument sterilization room, chang-

July – August 2010 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine
Rajpura, Boutros, Khan, et al 363
Rajpura © 2010 Prehospital and Disaster Medicine
Figure 1—Distribution of patients by age and sex
(Male mean age = 24.9 years; n = 30; Female mean age
= 22.9 years; n = 48)
Rajpura © 2010 Prehospital and Disaster Medicine
Figure 2—Injury types encountered
Rajpura © 2010 Prehospital and Disaster Medicine
Figure 3—Injury types encountered (continued)
Rajpura © 2010 Prehospital and Disaster Medicine
Figure 4—Theatre setup
Rajpura © 2010 Prehospital and Disaster Medicine
Table 1—Orthopedic procedures performed Rajpura © 2010 Prehospital and Disaster Medicine
Table 2—Plastic surgical procedures performed
Procedure Number
Performed
Examination under anaesthesia,
washouts and debridements 202
Manipulation under anaesthesia 5
Application of Hip Spica 2
K wiring of fractures 7
Open reduction and internal fixation of
long bones 5
Circular frame fixation without shortening 6
Circular frame fixation with acute
shortening 9
Total number of patients involved 60
Procedure Number Performed
Split Skin Grafts 21
Amputation 4
Revision of Amputation 11
Fasciocutaneous Flaps 17
Musculocutaneous Flaps 3 (1 Gastrocnemius, 1 Soleus,
1 Tensor Fascia Lata)
Free Flaps (Rectus) 1
Total number of patients
involved 46

Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol. 25, No. 4
364 Pakistan Earthquake
She made a good post-operative recovery and began
mobilizing with partial weight bearing.
Case 3: ORIF and Free Flap
A 16-year-old male was admitted with a compound left
ankle fracture that was cleaned and had a cast applied in
the field hospital. He underwent initial examination and
debridement under anesthesia, which revealed a 15 x 6 cm
defect medially. This was repeated two days later. The loca-
tion and size of the defect necessitated a f ree flap to gain
tissue cover. A free Rectus Abdominis flap and open reduc-
tion and internal fixation of the fracture was carried out
three days later (Figure 10). The flap took successfully and
the patient went on to make a good recovery.
room allowed three concurrent operations to be carried out
with the aid of local anesthetic and scrub staff (Figure 4).
This allowed for the high throughput of cases. A break-
down of procedures carried out is in Tables 1 and 2. Thirty-
four definitive orthopedic procedures (fixations) and 57
definitive plastics procedures were performed. Nineteen
procedures were performed jointly in which fractures were
fixed with external fixation followed by skin cover.
Initial work involved repeat debridement of grossly
infected open injuries that had been left untreated for four
weeks. Definitive procedures were performed on these
patients mainly during the second week.
Case 1: Ilizarov and Local Flap
A 6-year-old-girl had been admitted with open mid-shaft
left tibial fracture (Figure 5). She had undergone initial
debridement and application of a monolateral external fix-
ator prior to transfer to this unit.
Repeat x-rays showed an area of bone loss and
osteomyelitis (Figure 5). Examination under anesthesia
revealed an 8 x 6 cm soft tissue defect with exposed bone.
She underwent repeat debridement and eventual acute
shortening after excision of sequestrum. A fasciocutaneous
flap then was fashioned out to cover the soft tissue defect
and an Ilizarov frame was applied (Figure 6).
The distal tip of the flap failed to take, and therefore, was
advanced a week later. She made a good post-operative recovery.
Case 2: Taylor Spatial Frame and Local Flap
A 35-year-old woman was admitted with a compound,
comminuted left distal tibial fracture. She had undergone
initial stabilization with an ankle, bridging, monolateral,
external fixator (Figure 7).
She underwent initial examination under anesthesia and
debridement of the wound. The decision was made to per-
form an acute shortening and application of a Taylor
Spatial Frame. A fasciocutaneous flap was fashioned to
cover the soft tissue defect at the same time as the f rame
was applied (Figure 8).
Postoperative x-rays were taken and deformity correc-
tion was carried out using the online software accompany-
ing the Taylor Spatial Frame (Figure 9).
Rajpura © 2010 Prehospital and Disaster Medicine
Figure 5—Left: Initial post-operative x-rays, Right: x-
rays taken upon arrival
Rajpura © 2010 Prehospital and Disaster Medicine
Figure 6—Top: Pre-operative photo showing soft tissue
defect; Middle: Intra-operative photo while fashioning
the local flap; Bottom: Post-operative photo after
Ilizarov frame applied

July – August 2010 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine
Rajpura, Boutros, Khan, et al 365
rotational flap to gain soft tissue cover. A Tensor Fascia
Lata flap was carried out two days later (Figure 11b).
Drains and stitches were removed after two weeks. The
flap had taken successfully at this point and the patient was
discharged three days later.
Complications
No anesthetic complications were encountered during the
12 days. Early post-operative surgical complications main-
ly were related to plastic surgical procedures carried out to
provide soft tissue cover to compound f ractures. This
included one fasciocutaneous flap that necrosed complete-
ly and required revision, and a further three fasciocutaneous
flaps whose distal tips underwent necrosis. Two of these
required surgical debridement and advancement, which
were successful. Two amputations, one below knee, and one
symes amputation, suffered wound breakdown requiring
Case 4: Myocutaneous Flap
A 60-year-old woman was admitted to the unit after hav-
ing undergone a left above knee amputation secondary to
crush injury. This had rendered her bed bound and she
went on to develop a grade IV pressure sore over her right
greater trochanter. She underwent initial examination and
debridement under anesthesia, which left a 15 x 10 cm
defect over the trochanteric area (Figure 11a).
She underwent repeat examination under anesthesia
three days later and the decision was made to carry out a
Rajpura © 2010 Prehospital and Disaster Medicine
Figure 7—Pre-operative x-rays, Right: Soft tissue
defect on the anteromedial aspect of the left leg.
Rajpura © 2010 Prehospital and Disaster Medicine
Figure 9—Post-operative x-rays prior to final correc-
tion using computer aid
Rajpura © 2010 Prehospital and Disaster Medicine
Figure 11a—Pre-operative appearance of the pressure
sore
Rajpura © 2010 Prehospital and Disaster Medicine
Figure 8—Left: Pre-operative planning of the FC flap,
Right: Post-operative photo showing Taylor Spatial
Frame and Fasciocutaneous Flap
Rajpura © 2010 Prehospital and Disaster Medicine
Figure 10—Left: Pre-operative planning for rectus
flap, Right: Post-operative result
Rajpura © 2010 Prehospital and Disaster Medicine
Figure 11b—Post-operative appearance of the pressure
sore

Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol. 25, No. 4
366 Pakistan Earthquake
complicates further fracture management and significantly
delays recovery. With the use of ring fixators, more complex
injuries that had to undergo early amputation potentially
may have been salvageable.
All of the operative work was performed by members of
the team. However, the team did receive anesthetic and
nursing (scrub and ward) backup from local staff. This bal-
ance was essential; as it gave team clinical autonomy but
also helped provide peri-operative care for patients and to
train the local staff that were not always familiar with the
surgical techniques used.
However, this setup did lack physiotherapists and occu-
pational therapists, which will have hampered the ultimate
outcomes of the management. The team has now recruited
such allied health professionals to help with post-operative
management during future projects.
Another limitation of this setup was provisions for fol-
low-up of these patients. The majority of the patients had
been transferred from villages to the north of Islamabad
that stood in ruins. Once discharged from the unit, they
were transferred to emergency housing camps that had
been setup around Islamabad. Following the first two
teams, three smaller teams were sent on a weekly basis to
staff the trauma unit and provide continued care for the
remaining patients and short-term follow-up for the dis-
charged patients. Unfortunately, in the longer term, it is
estimated that half of the patients have been lost to follow
up, as they no longer had fixed residences where they could
be contacted.
Starting April 2006, a further three teams were sent on
a monthly basis to Ayub Medical College Hospital in
Abbottabad in the North West Frontier Province. This is
located in the region from which the majority of the
patients originally came. Their aim was to attempt to locate
and provide long-term treatment and follow-up for earth-
quake victims, irrespective of whether they originally were
not treated by the team. Efforts are continuing to setup a
limb reconstruction unit in Abbottabad in conjunction with
local medical staff.
Conclusions
Cultural sensitivity and local infrastructure analysis will
assist a medical team in providing appropriate surgical
interventions. Hence, collaboration with the local teams
who know the people, the area, and the problems was
essential to this effort. A multidisciplinary team effort in an
earthquake situation is much more likely to succeed in limb
salvage. The majority of the injuries involved limbs and
were open with soft tissue loss.
The number of cases requiring surgical intervention is
likely to be more than expected, and the team should be
prepared to work flexibly, and in collaboration with other
healthcare professionals. It also is important to have a des-
ignated lead person who can liaise with the local officials
and may be familiar with local circumstances.
The long-term welfare of the patients also must be con-
sidered and arrangements must be made to have the
patients followed-up safely. It is possible that techniques
used by the specialist teams are not familiar to the local
medical community.
operative debridement. Split skin grafting was required to
gain wound closure for the below-knee amputation.
Discussion
The aim of this project was to limit both morbidity and
mortality in survivors of the earthquake who had suffered
severe limb trauma through limb salvage operations and by
addressing the third peak in mortality seen in trauma
patients as described by Trunkey et al.4This peak is thought
to be due to late complications of the injuries sustained,
such as sepsis. This especially was relevant in the patient
population due to the high proportion of open fractures. In
order to accomplish the aims, resources were mobilized
from the UK. The self-reliant teams that travelled to
Pakistan consisted of plastic/orthopedic surgeons, junior
medical staff, anesthetists as well as scrub staff and operat-
ing room staff. The specialist equipment required by the
surgeons/anesthetists and disposables were brought by the
teams in order to avoid demand on already scarce local resources.
As demonstrated by the case mix presented, a joint
ortho-plastic approach was key to the success of this mis-
sion. Having arrived four weeks after the earthquake struck,
the majority of the cases encountered were infected, com-
plex, and/or open fractures that had only received initial
first aid treatment and primitive stabilization. Therefore, in
order to fulfill the objective of limb salvage, a team special-
ized in limb reconstruction, (both bony and soft tissue) was
essential. Of the 66 patients with bony injuries, only four
had to undergo fresh amputation and 11 revisions of ampu-
tations were carried out. Therefore, the amputation rate was
6% (overall 22% including revisions amputations). Without
surgeons skilled in limb reconstruction using ring fixators
and soft tissue reconstruction, a possible further 20 patients
would have required amputation.
Many individual surgeons had arrived before the team
and had done an admirable job. Unfortunately, due to the
limited resources available, complexity of the injury pat-
terns encountered, and perhaps the lack of experience in
some cases, some cases were encountered that had been
managed less than ideally, e.g., transphyseal medullary nail
fixation of fractures and inappropriate flaps with loss of
valuable tissue. Therefore, a team-based multidisciplinary
approach, along with specialized equipment such as ring
fixators, was necessary to tackle the complex cases encoun-
tered, which would have required tertiary care anywhere in
the world.
Mobilizing teams such in the immediate aftermath
logistically is challenging, and it took four weeks to gather
local information, setup a base and collect the essential
equipment for the team in this project. As suggested by
Laverick et al, a central register of future volunteers, includ-
ing surgeons and allied health professionals that would be
willing and available at short notice, would enhance the
response time in future efforts.11 In light of the large pro-
portion of open f ractures with soft tissue loss encountered,
earlier arrival especially could have helped this subset of
patients by providing quicker appropriate soft tissue man-
agement, potentially reducing rates of osteomyelitis that

July – August 2010 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine
Rajpura, Boutros, Khan, et al 367
5. Ahmad MA, Naqui SZ, Shah N, et al: The Pakistan earthquake: A British
trainee's experience. Injury 2006;37(6):567–569.
6. Bozkurt M, Ocguder A, Turktas U, Erdem M: The evaluation of trauma
patients in Turkish Red Crescent field hospital following the Pakistan earth-
quake in 2005. Injury 2007;38(3):290–297.
7. Helminen M, Saarela E, Salmela J: Characterisation of patients treated at the
Red Cross field hospital in Kashmir during the first three weeks of operation.
Emerg Med J 2006;23(8):654–656.
8. Mulvey JM, Awan SU, Qadri AA, Maqsood MA: Profile of injuries arising
from the 2005 Kashmir earthquake: The first 72 h. Injury 2008;39(5):554–560.
9. Siddiqi K: The Pakistan earthquake: A personal experience. Lancet 2006;
367(9515):986.
10. Yasin MA, Malik SA, Nasreen G, Safdar CA: Experience with mass casual-
ties in a subcontinent earthquake. Ulus Travma Acil Cer rahi Derg
2009;15(5):487–492.
11. Laverick S, Kazmi S, Ahktar S, et al: Asian earthquake: Report from the first
volunteer British hospital team in Pakistan. Emerg Med J 2007;24(8):543–546.
References
1. US Geological Survey: Northern Pakistan Earthquake of 8 October 2005. Available
at http://earthquake.usgs.gov/eqcenter/eqarchives/poster/2005/20051008.php.
Accessed 18 May 2008.
2. The International Federation of Red Cross and Red Crescent Societies:
Pakistan Earthquake FACTS AND FIGURES SHEET. Available at
http://www.ifrc.org/Docs/pubs/disasters/pakistan-earthquake/facts-figures-
1006.pdf. Accessed 18 May 2008.
3. Baker CC, Oppenheimer L, Stephens B, et al: Epidemiology of trauma
deaths. Am J Surg 1980;140(1):144–150.
4. Trunkey DD: Trauma. Accidental and intentional injuries account for more
years of life lost in the US than cancer and heart disease. Among the pre-
scribed remedies are improved preventive efforts, speedier surgery and further
research. Sci Am 1983;249(2):28–35.