美国创伤中心的发展

CLINICALORTHOPAEDICSANDRELATEDRESEARCHNumber422,pp.17–22

©2004LippincottWilliams&Wilkins

TraumaSystemDevelopmentinNorthAmerica

WilliamS.Hoff,MD,FACS*;andC.WilliamSchwab,MD,FACS

Theconceptsoforganizedtraumacare,manyofwhichorig-inatedinmilitarymedicine,havebeenproveneffectiveintheciviliansector.Aformaltraumasystemincludesallphasesofcarefromprehospitalthroughrehabilitation.Althoughtraumacentersassumetheleadershiprole,inatrulyinclu-sivesystem,allhealthcareproviders(prehospitalproviders,communityhospitals,andtraumacenters)haveadefinedroleinprovidingcaretopatientswithtrauma.Asaresult,patientsreceivetreatmentattheappropriateinstitution,re-sourcesareallocatedappropriately,andtheclinicaloutcomeisoptimized.Suchasystemideallyissuitedtotheuniqueneedsofthemasscasualtyscenario.

Initsmostbasicform,traumareferstophysicalinjurywhich,becauseofitsseverity,posesapotentialthreattolifeorlimb.Traumasystemshaveevolvedasanorganizedapproachtoprovideseverelyinjuredpatientsrapidinitialtreatment.Inkeepingwiththeaforementioneddefinition,traumasystemsaredesignedtopromoteoptimumcarealongacontinuumfromprehospitalcarethroughrehabili-tationtoprovidepatientswiththebestoutcomepossible.Theadvantagesofsuchanorganizedapproachseemlogi-calandideallysuitedtothemultiplecasualtysituation.However,althoughtheconceptoftraumasystemshasbeenreasonablywelldeveloped,rgeareasofthecountry,es-peciallymoreruralareas,lackrefinedsystemsoftraumacare.

Thissectionwillbeginwithabriefreviewofthees-sentialmedicalhistorypertinenttotraumasystemdevel-opment.WethenwilldescribetheconceptofthemoderntraumasystemandelaborateontheexperienceintheUnitedStatesandCanada.Finally,inthecontextofourcurrentnationalchallenge,wewilloffersomesummarypointsandsuggestionsonfuturedirectionsfortraumasys-temdevelopment.

From*St.Luke’sHospital,Bethlehem,PA;andthe UniversityofPenn-sylvaniaMedicalCenter,Philadelphia,PA.

Correspondenceto:WilliamS.Hoff,MD,FACS,St.Luke’sHospital,Dept.ofTrauma&SurgicalCriticalCare,801OstrumStreet,Bethlehem,PA18015.Phone:610-954-2200;Fax:610-954-6459;E-mail:hoffw@.DOI:10.1097/01.blo.0000128292.43913.83

BriefHistoryofTrauma

Majoradvancementsinclinicalcareandtraumasystemsdevelopmenthaveparalleledmilitaryhistory.AlthougheachwarthroughoutthehistoryofWesterncivilizationhashadsomecontributiontotraumasystemdevelopment,thefirstsignificantadvancemaybeattributabletoDom-iniqueLarreyduringtheNapoleanicWars.Inthelate1700s,Larreydevelopedthe“flyingambulance”totrans-portwoundedsoldierstodefinitivecare.Beforethisinno-vation,woundedsoldierssimplywereleftonthebattle-fielduntil,sometimesdaysaftercompletionofthebattle,theycouldberetrievedsafely.Inaddition,Larreyestab-lishedfieldhospitalsclosetotheactivecombat.7,22

Larrey’scontributionsrepresentthecornerstoneonwhichmoderntraumacareandtraumasystemshavebeenbuilt.Patientoutcomeafterinjuryisoptimizedbyrapidprovisionofdefinitivecare.

Significantdevelopmentsinciviliantraumamedicinelargelyhavebeentheresultofourtwentiethcenturymili-tarycampaigns.22DuringWorldWarI,anorganizedsys-temofcasualtytriagethroughprogressivelevelsofcarewasestablished.WoundedsoldierswereevacuatedviamotorizedambulancetoBattalionAidStationswheretheywereevaluated,treated,andreturnedtocombatortrans-portedtoahigherlevelofcare.22,25PhysiciansreturningfromWWIputtheBattalionAidStationconceptintoci-vilianpracticewiththedevelopmentofaccidentroomsdesignedtoevaluateinjuredandcriticallyillpatients.4IncreaseduseofthemotorizedambulanceinWorldWarIIalsoreducedtimetotreatmentforwoundedsoldiers(Table1).

Improvedradiocommunications,theuseofhelicopterstotransportinjuredsoldiers,andfront-linesurgicalhospi-talswereinnovationsoftheKoreanconflict.MobileArmySurgicalHospitals(MASHUnits)werecapableofprovid-inginitialsurgicalcareclosetothefrontlinesasopposedtosimplyservingastriagestations.Increaseduseofaero-medicaltransportalsoreducedtransportationtimeduringtheVietnamWar(Table1).22,25TheVietnamWaralsomarkedthebeginningoforganizedfieldcarewithspe-ciallytrainedmedics.Theseindividualslaterwouldbe-cometheparamedicsincivilianmedicine.4

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18HoffandSchwab

TABLECampaigns—Time1.TwentiethtoDefinitiveCenturyMilitaryCare

Campaign

MilitaryDefinitiveTimetoCare

Mortality

WorldWarI(WWI)12–18hours8.5%WorldWarII(WWII)6–12hours5.8%KoreanConflict2–4hours2.4%VietnamWar

65minutes

1.7%

DevelopmentofTraumaSystemsintheUnitedStatesInthehistoryofmedicine,traumasystemsmustbecon-sideredarelativelyrecentdevelopmentandonewhichisinitsearlyevolution.Inthelate1950sandearly1960s,severalstudiesshowedsuboptimalclinicaloutcomesincivilianpatientswithtrauma.15,16,24,28Asignificantnum-beroftraumamortalitieswerethoughttohavebeenavoid-ablewhenamoresystematicapproachtoseverelyinjuredpatientswasused.Outofthesestudies,theconceptofpreventabledeath,usedroutinelyinmodernperformanceimprovementreviews,wasidentifiedasonewaytomea-sureoutcomesintraumasurgery.

In1966,theNationalAcademyofSciencespublishedAccidentalDeathandDisability:TheNeglectedDiseaseofModernSociety,1whichhighlightedtheinferiorstateoftraumacareinthiscountryatthetime.This“whitepaper”alsodescribedthesignificantsocietalandeconomicim-plicationsassociatedwithprovidingsubstandardcaretoinjuryvictims.1Severalrecommendationsincluded:evalu-ationoftransportationmodalitiesforlesspopulatedareas;provisionofeducationalopportunitiesforprehospitalper-sonnel;completionofaresourceassessmenttodeterminewhatresourceswereactuallyavailableforthemanage-mentofseverelyinjuredpatients;establishmentofregis-triestoaccumulatedataspecifictopatientswithtrauma;andprovisionoffinancialsupportforspecializedcen-ters.12PublicationofthispapermarkedthebeginningofmodernEmergencyMedicalServices(EMS).5

Illinoisestablishedthefirstformalregionaltraumasys-temin1971.TheIllinoisTraumaProgramconsistedofdesignatedfacilitiesfortraumaandburncare,withthreecategoriesdefined:LocalTraumaCenter,AreawideTraumaServiceCenter,andRegionalTraumaServiceCenter.5 …… 此处隐藏：5928字，全部文档内容请下载后查看。喜欢就下载吧 ……