The surgical treatment of road accidents begins in the road. The scene of most accidents is far enough from hospital for a neglect of first-aid principles to allow deterioration in the patient's general condition. In some cases this tips the balance against survival.

All motorists should appreciate the importance of covering and stabilising open wounds before the victim is moved. Indeed, this is well enough known where there are obvious fractures of the long bones. But it is almost equally important for extensive soft-tissue damage, even without fracture; and this is less well known. In both types of injury the practice is less well observed than understood. All motorists, too, should find room in their car for a few first- aid dressings, a roll of strapping, and a pair of scissors. And all should acquire the simple skill needed to make the best use of them. In default of more elaborate apparatus, much good can be done by using one leg to splint the other, or by fixing an injured arm to the side of the body. Many people were taught the principles of first-aid in their school days, and many are glad of this when the moment comes. Many a surgeon, and many a patient, has cause to be grateful when these principles have been put into practice.

How many victims are efficiently splinted before they are moved? How many ambulances carry a sufficient variety of splints for this purpose? Do all accident ambulances carry two attendants, and, if they do, are these both companionably seated in front? How many of the patients travel with someone beside them to attend, minute by minute, to haemorrhage, respiratory obstruction, or vomiting? These are not rhetorical questions. We confess we do not know the answers; but we should. The patient, sometimes rightly, regards this journey as the most hazardous part of his calamity, and looks to arrival at hospital to end his troubles. Only too often he arrives depleted of strength which a little more skill and care might have preserved.

At hospital there may be an interval before definitive treatment can begin. It is often in the patient's own interest that there should be. Sometimes this first stop is no more than temporary, and - again in his own interest - he is to be moved on. Nevertheless, there is here an opportunity to revise the first-aid measures already applied; dressings may have to be changed and splints adjusted. Here, too, further preliminary treatment can be given. Shock may have to be dealt with almost at the moment of arrival. New casualty departments are being designed to include resuscitation rooms, and many old departments are improvising them. In some cases it is advisable to close wounds, or to reduce deformities which are producing complications, even if these operations have later to be repeated more precisely. A sucking wound in the chest, a pressure pneumothorax, severe respiratory obstruction, or a fracture-dislocation compressing a main vessel or nerve - these will not brook the inevitable delays associated with hospital admission and in-patient surgical arrangements. Facilities should be at hand for dealing with these emergencies. It is at the door of the hospital that the patient can be most profitably seen by an experienced surgeon. During the 1939-45 war many surgical units put their senior surgeons on to the reception of casual ties so that a surgical policy could be defined for each patient as soon as possible; the more junior surgeons worked in the theatres. There may be a lesson in this for the surgery of accidents, because it is not too fanciful these days to com pare the highroads with the battlefields. The man who makes the decision is often just as important as the man who makes the incision.

(from The Lancet, 23rd June, 1962)