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INFRARED LASER SYSTEM LSI 2030/90 • Ultra effective high-capacity com pact laser m eets the highest requirem ents. • First c om pact laser w ith special • grow th and healing frequencies (pituitary glands). • Digital quartz controlled frequency synthesis. • Digital polyfrequency spectrum . • Digital alpha frequency. Sole Agents: L A S E R - C D S M E D T E C H C C . Laser Equipm ent for C osm etic and M edical T re a tm e n t 63 Westwold/'ay Parkwood2193 Johannesburg S.A. Tel: 442-7578 * PPS - Because you just don't know when misfortune could strike PPS — Professional Cover For Professionals The best sickness and disability benefits, a tax-free lump sum on retirement, group term life cover, retirement annuity schemes and Profmed — the medical aid schem e tailored for the professional. Available to Graduate Professionals only. S o ... start out right, call PPS today. The Professional Provident Society of South Africa P.O. Box 1089 HOUGHTON 2041 Tel No: (011)486-1088 Fax No: (011) 486-2946. < 2 3 4 5 8 1 E R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) THE OPTIMAL PHYSIOTHERAPEUTIC APPROACH TO PENETRATING STAB WOUNDS OF THE CHEST M Senekal B Phys T UP, M Sc student,U niversity o f the W itwatersrand C Eales M Sc Physiotherapy, Department o f Physiotherapy, University o f the W itwatersrand INTRODUCTION Penetrating stab wounds of the chest are among the most common injuries seen in the casualty department at Hillbrow Hospital, Johannesburg. Out of a total number of 18,393 patients admitted to the hospital during a five year period (23 Feb­ ruary 1988 to 9 January 1993) 1,650 male patients were admitted with stab wounds of the chests. Of these patients, 1,255 re­ ceived intercostal drains, while the rest (395 patients) were managed without in­ tercostal drainage. The average age was 29.82 (max 88 years; min 15 years). The average number of days hospitalised for the group that received intercostal drains was 4,72 days (max 170 days; min 0 days). The patients who were managed without intercostal drains had spent an average number of 5,27 days in hospital (max 113 days; min 0 days). The fact that patients who were managed without intercostal drains had a longer hospital stay com­ pared to those managed with intercostal drainage was very interesting. Over the past decades radical changes have taken place in the management of penetrating injuries of the chest. Treat­ ment has swung from an aggressive surgi­ cal approach with a high thoracotomy rate to a more conservative policy using drain­ age by tube and observation. Hippocrates was the first to consider drainage of the pleural space when he described incision, cautery and metal-tubes to drain empye­ mas1. During World War I, there was some debate over the desirability of evacuating blood in the pleural space, those opposed arguing the accum ulatin g blood tam­ ponades the bleeding. This opposition gradually faded after the war, and by the time of World War II it w as the method of evacuating blood that became controver­ sial2. Current practice is individualised treat­ ment of the particular case, using intercos­ tal tube drainage, thoracotomy or thoraco- ^O PSO M M IN G ^ Penetrerende steekwonde van die toraks is van die mees algemene beserings w a t in die o ngevalle afdeling by Hillbrow Hospitaal in Jo­ hannesburg gesien word. Opinies met betrekking tot die sjirur- giese hantering van pasiente met hemopneumotorakse verskil. Die doel van hierdie studie was om te bepaal of daar 'n verskil in resul- tate sal wees tussen pasiente wat longfisioterapie onmiddellik na in- plasing van die inter-kostale drein ontvang, en daardie pasiente wat lo n g fis io te ra p ie la te r o n tv a n g . Gedurende 'n vergelykende studie is ses-en-twintig manlike pasiente met penetrerende steekwonde van die toraks, ewekansig tydens op- name by die Hillbrow Hospitaal aan een van twee groepe toegeken. Die pasiente in Groep I het long­ fisioterapie onmiddellik na inplasing van die interkostale drein gekry, ter- wyl p asien te in G ro ep II lo n g ­ fisioterapie nege tot tw aalf ure later gekry het. Gemiddelde duur van in­ terkostale dreinasie in Groep I was 40,00 ure en in Groep II 65,92 ure. Pasiente in Groep I het 'n gemid­ delde duur van 43,96 ure hospitaal- verblyf gehad, terwyl oasiente in Groep II 'n gemiddelde hospitaal- verblyf van 77,53 ure gehad. Die - prevalensie van pasiente met pirek- sie was ook betekenisvol minder in Groep I as in Groep II. Hierdie studie dui daarop d a t die aggressiewe protokol van longfisioterapie on­ middellik na inplasing van die inter­ kostale drein definitiewe voordelige resultate oplewer. Sleutelwoorde: p e n e tre re n d e steekwonde, fisioterapie. V____________ .___________ J abdominal exploration as indicated . It is known for a long time that the majority of penetrating wounds of the chest can be successfully treated with an intercostal chest tube, thoracotomy being reserved for specified cases4,5,6'7'8'9. Several authors in their studies on haemopneumothoraces m en tio n that p a tie n ts receiv ed ch est physiotherapy during their stay in hospi­ tal, but no treatment details on the time ^SUMMARY ^ Penetrating injuries to the chest are among the most common injuries seen in the casualty departm ent at Hillbrow Hospital, Johannesburg. Opinions regarding the surgical handling of patients with penetrat­ ing chest trauma continue to differ. The purpose of this study was to determine whether there would be a difference in outcom e in patients who receive chest physiotherapy immediately after insertion of the intercostal drain versus those p a ­ tients who receive chest physio­ therapy nine to twelve hours later. In an effort to optimise the physio­ therapy m anagem ent of patients with penetrating stab wounds to the chest, a comparative study was conducted at Hillbrow Hospital, Jo­ hannesburg. Twenty six male p a ­ tients between the ages of eight­ een to thirty years were randomly allocated to one of two groups on admission to the Hospital. The patients in Group I received chest physiotherapy immediately after insertion o f the intercostal drain while patients in Group II re- ■ ceived chest physiotherapy nine to twelve hours later. Mean duration of time of intercostal drainage in Group I was 40 hours and in Group II 65,92 hours. Patients in Group I had a mean hospital stay of 43,96 hours, wnile patients in Group II had a mean hospital stay of 77,53 hours. The prevalence of patients with spiking temperatures was also sig­ nificantly lower in Group I than in Group II. This study suggests that the p ro to c o l o f an aggressive a p ­ proach of immediate chest physio­ therapy in these patients has defi­ nite beneficial results. Key words: P enetrating injuries, physiotherapy. V_________________________ J that chest physiotherapy commenced or the format of chest physiotherapy, are given10. The majority of these patients are ad­ mitted during the evening or at night and the normal procedure at most hospitals is that they are only treated the following day when the physiotherapists come on duty. Beneficial results (shorter duration of hospitalisation, shorter intercostal drain­ age times and a lower prevalence of com­ plications) as a result of early chest physio­ therapy commencing on insertion of the intercostal drain, were described in pa­ tients with stab wounds o f the chest in 197311. Physiotherapy, May 1994 Vol 50 No 2 Page 29 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) O G R A D Y P E Y T O N i n t e r n a t i o n a l USA CALLING EXCELLENT OPPORTUNITIES $ 2 , 0 0 0 SIGN-ON BONUS PHYSIOTHERAPISTS/OCCUPATIONAL THERAPISTS O’GRADY-PEYTON INTERNATIONAL recruits close to 4 0 0 healthcare professionals each year for hospitals all over the USA. That’s trust. That’s experience! W e know where the best jobs are! W e know how to provide the best advice and support along each step of the way. W e take care of all the licensing and visa processing (both H -1 and Green Card). W e provide an excellent salary and benefits package which includes free furnished accommodation for a whole year, free flights beginning and end of contract, free Medical Aid, insurance etc. We also offer a U S$2,0 0 0 (US Dollars) sign-on bonus to help you get started, purchase a car etc. You won’t beat that. Please call E ileen Bryans, T el No. (024) 5 1-6114 and we will take it on from there. Head office 4 7 0 Atlantic Avenue 8th Floor Boston Massachusetts 0 2 210 Tel: (6 1 7 )4 8 2 -5 6 5 5 Fax: (6 1 7 )4 8 2 -1 5 5 1 Susan Barker 7370 Hodgson Memorial Drive, Savannah Georgia 3 1 405 Tel: (9 1 2 )3 5 3 -9 3 6 6 Fax: (912) 3 53-9341 Eileen Bryans Manager for S Africa PO Box 766 Somerset West 7129 Tel: (024) 5 1 -6114 Fax: (0 2 4 )8 5 2 -5 5 0 8 STARTED BY MEDICAL PEOPLE FOR MEDICAL PEOPLE ^ S tQ R y h a b , Inc. SCIENCE O F M O T IO N YOU PICK YOUR SPECIALTY Orthopaedics, paediatrics, work hardening, acute care, rehabilitation, psychiatry and more. YOU PICK YOUR LOCATION Our priority is to design a satisfying match between therapist and geographic area. Choose where you want to go, we do nationwide placements. WE’LL DO THE REST All expenses paid. StaRyhab completes and pays for credentialling, licensing and immigrations, air fare, relocation cost, and professional insurance. EXTRAS: Continuing education, medical insurance, paid leave, orientation period in Cleveland, Ohio (including expenses, accommodation, lectures/ instructions on working conditions and assistance with the licensing examination. StaRyhab, Inc. 1250 OLIVER ROAD CLEVELAND, OH 44113 U.SA. PHONE: (216) 861-8000 FAX: (216) 861-8050 StaRyhab, Inc. places Physical and Occupational Therapists throughout the USA. Meet Karen Stary, a qualified Occupational Therapist and President of Sta­ Ryhab, Inc. for detailed information on actual working conditions in America. Presentations will be at the following: PRETORIA: Holiday Inn Thursday, 12 M ay 19h00 Holiday Inn Garden Court (Old Johannesburg Sun) Monday, 16 M ay 19h00 BLOEMFONTEIN: Holiday Inn Garden Court Naval Hill Thursday, 19 May 19h00 CAPE TOWN: Ambassador Hotel, Bantry Bay Monday, 23 May 19h00 DURBAN: Holiday Inn Garden Court North Beach (Old Maharani) Thursday, 26 May 19h00 JOHANNESBURG: CALL COLLECT 0800 990001 AND ASK FOR 216-861 -8000 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) With increasing pressure for the avail­ ability of surgical hospital beds and re­ sources, it is important to optimise the ef­ fectiveness of chest physiotherapy in pa­ tients with haemopneumothoraces due to penetrating stab wounds to the chest. The aim of this study was to determine whether there would be a difference in outcome in patients who receive chest physiotherapy immediately after insertion of the intercostal drain versus those pa­ tients who receive chest physiotherapy nine to twelve hours after insertion of the intercostal drain. Comparisons between the two groups were made, using the following parame­ ters: • Duration of intercostal drainage. • Duration of hospitalisation. • P r e v a le n c e o f s p ik in g te m p e ra ­ tures.(Prolonged intercostal drainage tim es are associated with increased in­ fection rates and morbidity10). PATIENTS AND METHODS This study was conducted at the Hill- brow Hospital, Johannesburg over a five m onth period (January to M ay 1993). Twenty six male patients between the ages of 18 to 30 years, with unilateral penetrat­ ing stab wounds to the chest were included in this study. The patients participating in this study were all haemodynamically sta­ ble on admission. Penetration was clini­ cally assessed and confirmed radiologi- cally before the patient was admitted to the series. All patients had an inspiratory chest radiograph taken on admission which was repeated after insertion of the intercostal drain and at intervals dictated by the clini­ cal progress o f the patient. All. patients with pneumothoraces with a rim of in­ trapleural air from the lung border to the inside of the thoracic wall at the level of the anterior bony end of the third rib , meas­ uring 1,5 centimetres or more wide and all patients with fluid levels up to the angle of the ninth rib or above, as assessed radiog- raphically, were included in this study. Radiological assessment of chest radio­ graphs were done during the course of this study by the same radiologist. Patients who were admitted with ten­ sio n p n e u m o th o ra c e s , su ck in g ch e st wounds, previous chest trauma, other in­ juries, eg. head injuries and cardiac injuries or patients on antibiotics for pre-existing infections for unrelated disease, were ex­ cluded from this study. Patients who were admitted to hospital more than 8 hours after the stabbing were also excluded. All patients had intercostal drains in­ serted in the fifth intercostal space in the midaxillary line in order to have a ho­ mogenous group of patients. All patients were given tetanus toxoid and broad spec­ trum antibiotics. Sufficient analgesia was provided by paracetamol with or without codeine or pethidine, to enable patients to breathe deeply ana ccugh without undue discomfort. The protocol for this study was accepted by the Committee for Re­ search on Human Subjects. After informed consent had been ob­ tained patients were randomly allocated to one of two groups, depending on whether a red or a blue card was drawn from an envelope. Group I received chest physio­ therapy immediately after insertion of the intercostal drain. Group II received chest physiotherapy nine to twelve hours after insertion of the intercostal drain. After in­ itial treatment, both groups received chest physiotherapy twice daily until removal of the intercostal drain. Physiotherapy for both groups was standardised. SPECIFIC ROUTINE ADOPTED FOR PATIENTS IN BOTH GROUPS SITTING: • Unilateral lateral costal breathing, pos­ terior basal breathing, diaphragmatic breathing. • Both hands behind the head, bend trunk forw ard (flexio n ) and touch knees with forehead. Combine with in­ spiration and expiration. Repeat 10 times. • Arms at side, side flexion of trunk to both sides. Repeat 10 times to both sides. If fluid drains in one of these po­ sitions, keep position and cough. • Arms bent, right elbow moves to touch left knee and vice versa. Repeat 10 times to both sides. • Coughing. • Brisk walking on the spot - lift knees to the level o f hips. One minute. • Deep breathing exercises. Unilateral lateral costal breathing, posterior basal breathing and diaphragmatic breath­ ing. • Coughing. STANDING: • Arms stretched above head, inspiration and then trunk flexion so that hands touch the floor whilst patient exhales. If fluid drains in this flexed position, keep position and combine with coughing and deep breathing exercises. Repeat 10 times. • Arms at sides, lateral flexion to both sides. If fluid drains in this lateral flexed position, keep position and combine with coughing and deep breathing ex­ ercises. Repeat 10 times. • Arms yard. Circular movements of the arms. Big circles - Repeat 10 times. Small circles - repeat 10 times. • Deep breathing exercises - unilateral lateral costal breathing, posterior basal breathing and diaphragmatic breath­ ing. • Coughing • Feet astride, arms yard, bend and touch right foot with left arm, return to start­ ing position and then vice versa. Repeat both sides 10 times. • Brisk walking on the spot (2 minutes). Brisk walking around in ward (2 min­ utes). Running up stairs (2 minutes). Do this exercise depending on what the pa­ tient can manage. • Coughing. Trunk exercises w ere done because changes in posture tend to move the in­ trapleural contents towards the site of the drain which had been inserted in the fifth intercostal space in the midaxillary line. T h ese ex ercises h elp ed flu id th at lay basally in the pleural space to be mobilised to the site of the drain. Doctors who were responsible for the decision whether to remove the intercostal drain or not, did not know to which group the patients had been assigned to. The criteria for the removal of the drain were the following: • Clinical assessment that the lung had re-expanded and, if fluid had been pre­ sent initially that there was evidence of only a small amount o f remaining fluid. • Radiography revealed that the lung was expanded and/or that the fluid had been drained to a minimum. • Cessation of swinging of the intercostal drain. The intercostal drain was removed dur­ ing a Valsalva manoeuvre and the chest radiograph was repeated to confirm radio­ logical expansion of the lung. On discharge, patients were asked to return to hospital urgently if they experi­ enced any chest problems. Patients were reviewed clinically and radiologically at the outpatient depart­ ment within one week after discharge. STATISTICAL ANALYSIS In order to analyse the duration of inter­ costal drainage and duration of hospitali­ sation, Levene's test for variability was used to compare the two groups and to determine which further tests should be used to determine a significant difference. The separate t-test was used to determine a significant difference with p < 0,05 in both cases. In order to analyse the prevalence of tem peratures the P earson 's Chi-square test was used to compare the groups and to determine which further tests should be used to determine a significant difference. Fisher's exact test was used to determine a significant difference with p < 0 ,0 5 . continued on page 34... Physiotherapy, May 1994 Vol 50 No 2 Page 31 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) P H Y S I T M A N C C U P A _ “MRI supported our family in many ways, but most impor­ tant they put us in touch with a great employer whom I now work for. 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Founding Member A s s o c i a t i o n o f I n t e r n a t i o n a l H e a l t h C a r e R e c r u i t e r s & E m p l o y e r s (A IH R E ) Presentations throughout South Africa for the months of April & May For your convenience all presentations will be offered twice-at 1 lh 00 and again at 16h00: ■ JOHANNESBURG Sunnyside Hotel - 16 April 94 ■ PRETORIA Holiday Inn - 23 April 94 ■ PORT ELIZABETH Holiday Inn Garden Court - 30 April 94 ■ CAPETOWN Bellville Inn - 14 May 94 ■ DURBAN Holiday Inn Marine Parade- 21 May 94 lly: 051-489-972 • Fax:515-472-1897 , Philippines, South Africa, U.K., and U.S.A. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 120 GROUP I GROUP II | MAXIMUM | £ ] MINIMUM | MEDIAN Q ] MEAN Figure 1. Duration of Intercostal Drainage MAXIMUM MINIMUM MEDIAN MEAN Figure 2. Duration of Hospitalisation D IS C O V E R A M E R IC A Five hundred years ago Columbus discovered America. Today, Action Medical is right here in South Africa helping physiotherapists and occupational therapists to make similar discoveries of their own. Some are travelling the continent, exploring a wide variety of destinations by working on short assignments. Others have taken prestigious positions in locations of their choice. And more are developing specialist skills in private clinics throughout the country. ACTION MEDICAL HAS HELPED THEM ALL! AAAACTION MEDICAL SAINTERNATIONAL RECRUITMENT CONSULTANTS PO Box 503. CONSTANTIA 7848, CAPE TOWN TEL: (021) 794 7736 FAX: (021) 794 2049 Our status as independent relocation consultants, together with our wide range of contacts and experience throughout America, will ensure that you benefit from Excellent opportunities - only the best available positions in the USA and Canada Top rates of pay - guaranteed to be on a par with your American colleagues Personal service - we’re always on hand to help with the many aspects of your move. Let Action Medical link you to a New World of opportunity. Call Julia Swain now on 021 794 7736 or send your CV to us today. We will send you a full information pack by return of post. The rest is plain sailing! Bladsy 34 Fisiotergpie, M§i 1994 Deel.5.0 no 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) RESULTS Duration of intercostal drainage (See figure 1, page 34) The m axim um length o f intercostal drainage in Group I was 54,0 hours with a minimum of 32,0 hours.- The median was 37.0 hours (Mean 40 hours; Range 22; S D ± 7 ,1 7 ). In Group II the maximum length of in­ tercostal drainage time was 102,0 hours with a minimum of 49,0 hours. The median was 58,0 hours (Mean 65,92 hours; Range 53; S D ± 16.16). Levene's test for variability was used for a significant difference with p=0,05. Using the separate t-test, there was a sig­ nificant difference (p=0,0001) in intercostal drainage times between the two groups with Group I having significantly shorter intercostal drainage times than Group II. There was no relationship between the du­ ration of intercostal drainage and the age of patients. Duration of hospitalisation (See figure 2, page 34) The maximum length of time spent in hospital in Group I was 72,0 hours with a minimum of 32,0 hours and a median of 37.0 hours (Mean 43,96 hours; Range 40; S D ± 13,29). In Group II the maximum length of time spent in hospital was 151,0 hours with a minimum of 54,0 hours. The median was 61.0 hours (Mean 77,53 hours; SD + 28,78). Levene's test for variability was used. Using the separate t-te s t, there was a sig­ nificant difference(p=0,0001) in the dura­ tion of hospitalisation between the two groups, with Group I having significantly shorter periods of hospitalisation than Group II. There was no relationship between the age of the patients and the duration of hospitalisation. Prevalence of spiking temperatures Two patients in Group I and five pa­ tients in Group II presented with spiking temperatures within the first twenty four hours after admission. Another three pa­ tients in Group II presented with spiking temperatures within the next twenty four hours. Using Fisher's Exact test (one tail), there was a significant difference (p=0,0207) be­ tween the groups regarding the preva­ lence of spiking temperature, with patients in Group I having significantly less spiking temperatures than patients in Group II. No cases of empyema or wound sepsis were seen in either of the groups. DISCUSSION Hillbrow Hospital is a large, busy, aca­ demic hospital for patients mainly from Johannesburg city and the surrounding suburbs. The incidence of trauma, includ­ ing penetrating chest wounds, is high. Penetrating injuries of the chest appear to be frequent in most metropolitan areas, according to Adkins et al17'. Miller et al13 reported that, over a ten year period end­ ing in the 1970s, the number of patients with stab injuries treated in New York City hospital doubled, while bullet wounds to the chest increased by fifteen times. It is also a perception of the casualty staff at Hillbrow Hospital that the ten­ dency towards gunshot wounds in rela­ tion to stab wounds has increased during the past year. A conservative approach to the man­ agement of stab wounds to the chest has evolved over the years 5,6,14 and this has been the case at the Hillbrow Hospital as well. The aims are to avoid unnecessary thoracotomy, to drain large collections of fluid or air from the pleural space rapidly and efficiently, resulting in an early re­ moval of chest drains, thereby avoiding any complications arising from their pro­ longed presence. Th e a g g re s s iv e a p p ro a ch o f ch est physiotherapy immediately after the in­ sertion of the intercostal drain has definite beneficial results. The duration of intercos­ tal drainage in this group of patients was at least twenty four hours shorter than in the group of patients who received physio­ therapy nine to twelve hours after inser­ tion of the intercostal drain. The prevalence of spiking temperatures was also significantly smaller in Group I than in Group II. Due to this fact, the du­ ration of hospitalisation of patients in Group I w as on the average 1,4 days shorter than that of patients in Group II. Knottenbelt et alw in their study on pa­ tients w ith simple pneum othoraces re­ ported a mean hospital stay of twenty two hours duration for non-leakers and forty nine hours for those patients with continu­ ous air leaks. The patients in this study who received chest physiotherapy nine to twelve hours after insertion of the intercostal drain had a mean hospital stay of 77,53 hours mean. It should be considered that 84,6% of the patients in this group presented with a haemopneumothorax and not just a sim­ ple pneumothorax as was the case in the study of Knottenbelt et a lw . M uckart13 mentions that the fact that both air and blood are present in the pleural cavity may reflect the severity of the assault. It is therefore not possible to compare the results of this study with the results of the study of Knottenbelt et al10 as it seems that patients ir. this study w ere slightly more traumatised. The attendance at the outpatient de­ partment at Hillbrow Hospital is poor, ow­ ing to socio-economic factors. If patients re m a in a sy m p to m a tic fo llo w in g d is­ charge, they return to their previous occu­ pation as soon as possible. Time lost in attending hospital leads to loss of earnings and a possibility o f redundancy. Only thirty eight percent of patients who partici­ pated in the study attended outpatient fol­ low-up clinics, and those who did attend, required no further treatment. Conclusions as to whether this protocol (the co m m en cem en t o f ch e st p h y sio ­ therapy immediately after insertion o f the intercostal drain) can be equally applied in the case of gunshot wounds to the chest, would be premature, as these injuries are generally more lethal and are associated with more extensive destruction of tissue. CONCLUSION Although the number of patients sur­ veyed in this study were small, the pa­ rameters used to assess the role of physio­ therapy suggest a beneficial result when physiotherapy is instituted immediately after insertion of the intercostal drain. The benefits are: • a shorter duration of intercostal drain­ age and hospitalisation in these pa­ tients, • lower prevalence of spiking tempera­ tures in these patients, • earlier discharge from hospital and a resultant earlier return to work, and • saving on basic hospital costs. It would therefore seem necessary for the ideal management of a patient with a stabbed chest that the surgical team should be supplemented with the presence of a physiotherapist in order to treat these pa­ tients immediately after insertion of the intercostal drain. REFERENCES 1. Hippocrates, Writings. In: Great books o f the Western World. Hutchins RA, ed Chicago: Encyclopedia Britannica Inc, 1952; 29:42. 2. Lewis FR. Haemopneumothorax. In: Trunkey DD and Lewis FR (eds). Current Therapy o f Trauma, 2nd e d itio n , P h ila d e lp h ia : BC Decker, Inc 1986:239. 3. Kaulesar DMKS, de Zeeuw GR, Brummel- kam p WH. Sharp th oracic injury. Injury 1989;20(l):22-26. 4. Melissas J, Diamantis T, Mannell A. Axillary intercostal drain in traumatic haemopneu­ mothorax. S A fr M ed J 1989;70 :588-589. 5. Hegarty MM. A conservative approach to penetrating injuries to the chest. Experience w ith 131 s u c c e s s iv e c a s e s . Injury 1076;8(l):53-59. continued on page 36... Physiotherapy, May 1994 Vol 50 No 2 Page 35 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) W ORLD CO NFEDERATIO N FOR PHYSICAL THERAPY POSITION O F SECRETARY GENERAL .. .continued from page 35 6. Oparah SS, M andal AK. Penetrating stab wounds of the chest: Experience with 200 consecutive cases. } Trauma 1976;16(11):868- 872. 7. Oparah SS, Mandal AK. Operative manage­ ment of penetrating wounds of the chest in civilian practice. J Thorac Cardiovasc Surg 1979;77(2):162-167. 8. Borja AR, Randsdell HT. Treatment of pene­ trating gunshot wounds of the chest: Experi­ ence with one hundred forty five cases. Am J Surg 1971;122,81. 9. Mattox KL, Allen MK. Systemic approach to pneumothorax, haemothorax, pneumome­ diastinum and subcutaneous emphysema (symposium paper). Injury 1986;17,309. 10. Knottenbelt JD, van der Spuy JW. Traumatic pneumothorax: a schem e for rapid patient turnover. Injury 1990;21(2):77-80. 11. Thaning A, Bremner C. The stabbed chest: Response to early physiotherapy. S A fr J Surg 1973;11(4):213-216. 12. Adkins RB, W hiteneck JM, W oltering EA. Penetrating chest wall and Thoracic Injuries. Am Surg 1985;51(3):140-148. 13. Miller DW, Hutchinson JE, Malm JR. Chest trauma: its nature in urban ghetto. NY State } M ed 1976;(7):1103-105. 14. Muckart DJJ. Delayed pneumothorax and haemothorax following observation for stab wounds of the chest. Injury 1985;16(4):47. The W orld Confederation for Physical The rap y (WCPT) is seeking a n e w Secretary G e ne ra l to co m m en ce e m p lo y m e n t on 1 Ju ly 1995. The Secretariat is established in London, UK, w h e re th e C o n fe d e ra tio n ow ns Headquarters property. WCPT has represented physical therapy in terna tion ally fo r over 40 years, is classified as an In te rn a tio n a l N on Governmental Organisation fINGO) and is non political and non profit making. It seeks to promote and maintain the status, education and high standard o f practice o f physical therapists worldwide. The Secretariat is small and applicants must be used or willing to work in a self sufficient, self-motivating environment and be responsible for all administrative and financial aspects of the Confederation management. The Secretary General represents the C o n fe d e ra tio n in discussions w ith in te rn a tio n a l agencies, g o ve rn m e n t agencies, other health professions and th e p u b lic , re q u irin g d ip lo m a cy, negotiation, leadership, advocacy and \ambassadorial skill. In addition he/she should be entrepreneurial, able to plan and im p le m e n t projects. A pplicants should have a qualification at university level, id e a lly in physical th e ra p y - candidates w ith international association o r o th e r re le v a n t e x p e rie n c e are encouraged to apply. The post provides o p p o rtu n itie s for interaction at highest international level a n d m a jo r tra v e l c o m m itm e n ts . Applicants should speak English fluently and some knowledge o f other languages w ould be an advantage. Compensation is negotiable but will be in keeping with th a t fo r c o m p a ra b le in te rn a tio n a l executive positions. Interested persons are invited to write, phone or fax for a copy o f the position description and other details. Applications are to be received by 1 June 1994, and will be treated w ith total confidentiality. Shortlisted candidates will be invited for interview on Saturday 16 July 1994 in London, UK. WCPT, 4a Abbots Place, London NW6 4NP (UK Reg C harity 234307). Tel: 071-328 5448, Fax: 071-624 7579. ____________________________ J B o t s w a n a is an in d e p e n d e n t , m o d e r n A fr ic a n c o u n t r y w ith s ta b le e c o n o m ic p r o s p e c ts o ffe r in g sig n ific a n t t a x b e n e fits t o e x p a t r ia t e s an d th e o p p o r tu n ity to r e m i t s a la r y w o r ld w id e . G a b o r o n e , th e ca p ita l, o ffe r s an a t t r a c t iv e a n d s o c ia b le o u t d o o r life s ty le w ith g o o d p r iv a t e s c h o o lin g fa c ilitie s o f a h igh s ta n d a r d . If you’d like to work in the US, contact HPI. We’ve helped more physical therapists find great jobs in America than any other recruiter. Top pay, expert licensing and visa processing. Fees paid by your employer. IIIIIIHPfK *)I .S ’ t The L eader in In ternatio n al H ealth care R ecruiting 812 Oak Street, Winnetka, IL 60093 USA (Reverse Charges) 708-441 -8384 Fax: 708-441-8401 Physiotherapist A vacancy exists for the position of Physiotherapist at Gaborone Private Hospital. The Hospital is part of Afrox group, one of the largest hospital management companies in the Southern African region. We require the services of a Physiotherapist to join our complement. Duties will mostly entail hospital based physiotherapy with attention to ICU, Orthopaedics and other patients. Applicants should be fully registered with a professional medical institution. Non-citizens will be offered: - 2 year contract with an attractive salary and a 25% tax free terminal’ gratuity. - Non contributory medical aid scheme. - Professional indemnity insurance A competitive salary will be offered to the right candidate. Applications with full Curriculum Vitae and a copy of registration certificate should be sent to: The Personnel Resource Manager Gaborone Private Hospital Private Bag BR 130 Gaborone 4 G A B O R O N E P R I V A T E H O S P I T A L Bladsy 36 Fisioterapie, Mei 1994 Deel 50 no 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )