Zentralblatt für Chirurgie
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Review Case Reports
[Ethical challenges in preclinical emergency medicine].
Out-of-hospital emergency medicine, just like any other medical field, must be guided by general ethical principles of medical action. These include respecting the patient's autonomous decision, acting for his benefit, avoiding harm, and justice in distributing the available means. The confrontation with ethical conflicts in the routine of emergency medicine is illustrated by a case report. ⋯ Physiologically defined futility justifies the decision to withhold resuscitative efforts. In a particular case the refusal by the patient as well as an expected bad prognosis which is inconsistent with the patient's interest could support the emergency physician's decision not to initiate resuscitation. Such an individual decision should not only be guided by medical, but also by ethical considerations and be based on general ethical principles.
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Traditional medical treatment approaches for incurably and terminally ill persons are often felt by the patients and their families to be lacking, since distressing physical and spiritual symptoms of the disease cannot be adequately addressed. In many cases, care in the final stage of life represents a complex medical challenge whose objective is to maintain an individually sufficient quality of life for the patient. New strategies for therapy and care evolving out of the international hospice movement have entered medical training programs under the heading of palliative medicine. ⋯ In the public itself a changed and more open treatment of the topics of death and dying is becoming apparent, resulting in a demand as well for medical treatment options. From all this, as well as the fact that Germany has been strongly hesitant to establish palliative medicine facilities, it is apparent that there is a clear need to catch up in the area of palliative medicine treatment, research and teaching. The current mood of fiscal restraint in health care may delay medical progress, but it will not be able to prevent it.
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From 1000 patients referred with diagnosis of appendicitis 483 were treated operatively, 517 conservatively. Laparotomy and histopathologic examination confirmed the correct indication for surgery in 95.2% of patients with preoperatively expected perforation, in 72.0% with the diagnosis of acute inflammation, and in 84.0% when a chronic disease was anticipated preoperatively.
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Review
[Dislocation fractures in the area of the middle foot--injuries of the Chopart and Lisfranc joint].
Dislocation fractures of the Chopart and Lisfranc joint line result from rough force and lead to articular incongruities, complex derangement of the plantar arc geometry and shortening of the medial or lateral column of the foot. These injuries are often complicated by severe soft tissue damage causing a high incidence of compartment syndrome. Beside careful clinical examination radiographs in 3 standard projections are essential for the exact diagnosis, if necessary completed by conventional tomographies or CT. ⋯ Dislocation-fractures of the Lisfranc joint can be fixed by percutaneous K-wires if a closed reduction is possible. Open reduction and internal fixation are indicated in cases of instable and irresponsible fractures, and in open fractures as well as in lesions presenting with a compartment syndrome. A precise anatomic reduction of the tarsometatarsal joints is critical after this kind of injuries to avoid long-term disability.
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Like other industrial countries Germany experiences a significant increase of cancer prevalence. Recent advances in the treatment of various types of cancer resulted in prolonged survivaltimes of patients. Cancer--especially in advanced incurable stages--often is accompanied by severe pain. ⋯ Most cancer-patients should experience sufficient pain-management if existing recommendations for the pharmacological treatment of cancer-pain (e.g. WHO-guidelines) are followed consequently. In case of intractable pain or ongoing disabling symptoms despite proper therapy consultation of an expert in palliative medicine should always be considered as well as the option to refer the patient to a specialized pain-management center.