Article(id=1208795419145016292, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1208795418612339683, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.2021.10.17, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1611676800000, receivedDateStr=2021-01-27, revisedDate=1622304000000, revisedDateStr=2021-05-30, acceptedDate=null, acceptedDateStr=null, onlineDate=1766128886257, onlineDateStr=2025-12-19, pubDate=1635350400000, pubDateStr=2021-10-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1766128886257, onlineIssueDateStr=2025-12-19, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1766128886257, creator=13701087609, updateTime=1766128886257, updator=13701087609, issue=Issue{id=1208795418612339683, tenantId=1146029695717560320, journalId=1189873630562394117, year='2021', volume='46', issue='10', pageStart='955', pageEnd='1060', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1766128886129, creator=13701087609, updateTime=1766128956061, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1208795711982924071, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1208795418612339683, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1208795711982924072, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1208795418612339683, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=1056, endPage=1060, ext={EN=ArticleExt(id=1208795419417646054, articleId=1208795419145016292, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Progress in application of the US military joint trauma system and its enlightment for combat casualty care in our army, columnId=1190243275882729994, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Review, runingTitle=null, highlight=null, articleAbstract=

Combat casualty care is a systematic project which ensures order and high-efficient rescue of casualties. The US army gradually established a joint trauma system in the wars in Afghanistan and Iraq, which reduced the combat casualty rate to a historically lowest level and improved the efficiency of combat casualty care. The present article reviews the background and development of the US military joint trauma system, expounds its mission and management system, emphasizes its characteristics and positive role in combat casualty care, and discusses its enlightment for PLA. The in-depth study of the US joint trauma system may provide a useful reference for building the PLA joint trauma system, which can improve the efficiency of combat casualty care during modern wars.

, correspAuthors=Lei Su, authorNote=null, correspAuthorsNote=
*E-mail:
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战伤救治是一项系统性工程,美军在阿富汗及伊拉克战争中逐渐建立起联合创伤系统,使其伤死率降至历史最低,提升了战场救治效率。该文介绍美军联合创伤系统的建立背景及发展历程,阐述其管理体系、任务目标、主要特点及对美军战伤救治的积极作用,探讨该系统对我军战伤救治发展的启示意义。通过对美军联合创伤系统的深入研究,可为我军建设联合创伤系统,提升现代战争条件下的战伤救治效率提供有益借鉴。

, correspAuthors=苏磊, authorNote=null, correspAuthorsNote=
苏磊,E-mail:
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华黎电,副主任医师,主要从事院前急救及救护车转运方面的研究

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美军联合创伤系统应用进展及其对我军战伤救治的启示
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华黎电 1, 2 , 张鹏 1 , 苏磊 1, *
解放军医学杂志 | 综述 2021,46(10): 1056-1060
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解放军医学杂志 | 综述 2021, 46(10): 1056-1060
美军联合创伤系统应用进展及其对我军战伤救治的启示
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华黎电1, 2, 张鹏1, 苏磊1, *
作者信息
  • 1南部战区总医院重症医学科,广州 510010
  • 2南部战区总医院质量管理科,广州 510010
  • 华黎电,副主任医师,主要从事院前急救及救护车转运方面的研究

通讯作者:

苏磊,E-mail:
Progress in application of the US military joint trauma system and its enlightment for combat casualty care in our army
Li-Dian Hua1, 2, Peng Zhang1, Lei Su1, *
Affiliations
  • 1Department of Critical Care Medicine, General Hospital of Southern Theater Command of PLA, Guangzhou 510010, China
  • 2Department of Quality Management, General Hospital of Southern Theater Command of PLA, Guangzhou 510010, China
出版时间: 2021-10-28 doi: 10.11855/j.issn.0577-7402.2021.10.17
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战伤救治是一项系统性工程,美军在阿富汗及伊拉克战争中逐渐建立起联合创伤系统,使其伤死率降至历史最低,提升了战场救治效率。该文介绍美军联合创伤系统的建立背景及发展历程,阐述其管理体系、任务目标、主要特点及对美军战伤救治的积极作用,探讨该系统对我军战伤救治发展的启示意义。通过对美军联合创伤系统的深入研究,可为我军建设联合创伤系统,提升现代战争条件下的战伤救治效率提供有益借鉴。

美军  /  战伤救治  /  联合创伤系统

Combat casualty care is a systematic project which ensures order and high-efficient rescue of casualties. The US army gradually established a joint trauma system in the wars in Afghanistan and Iraq, which reduced the combat casualty rate to a historically lowest level and improved the efficiency of combat casualty care. The present article reviews the background and development of the US military joint trauma system, expounds its mission and management system, emphasizes its characteristics and positive role in combat casualty care, and discusses its enlightment for PLA. The in-depth study of the US joint trauma system may provide a useful reference for building the PLA joint trauma system, which can improve the efficiency of combat casualty care during modern wars.

US army  /  combat casualty care  /  joint trauma system
华黎电, 张鹏, 苏磊. 美军联合创伤系统应用进展及其对我军战伤救治的启示. 解放军医学杂志, 2021 , 46 (10) : 1056 -1060 . DOI: 10.11855/j.issn.0577-7402.2021.10.17
Li-Dian Hua, Peng Zhang, Lei Su. Progress in application of the US military joint trauma system and its enlightment for combat casualty care in our army[J]. Medical Journal of Chinese People’s Liberation Army, 2021 , 46 (10) : 1056 -1060 . DOI: 10.11855/j.issn.0577-7402.2021.10.17
现代战争高新技术武器及大规模杀伤性武器的应用,使战伤严重程度明显加重,成为战场上军人死亡及残疾的主要原因[1]。但美军近年来在历次战争中的伤死率呈下降趋势,从第二次世界大战时的19.1%降至越南战争的15.8%,尤其在最近的伊拉克战争及阿富汗战争中,美军的伤死率降至6%,为历史最低水平[2]。以联合创伤系统(joint trauma system,JTS)为代表的战伤救治举措,在减少美军战场伤亡中发挥了重要作用[3]
JTS是美军为了提升战场救治效果,借鉴平时创伤系统的救治经验,以大数据为支撑,采用循证医学的方法,结合大量临床实践指南(clinical practice guidelines,CPGs)的应用而建立的战时创伤系统,其在美军联合战场创伤系统(joint theater trauma system,JTTS)及圣安东尼奥美国陆军外科研究所联合创伤系统(San Antonio-based JTS)的基础上不断融合发展,为提高美军战伤存活率发挥了重要作用[4]
在越南战争中,美军积累的快速后送并早期手术的经验促进了美国创伤中心的发展。越南战争后,前线的军医们意识到需要建立一个系统性的创伤救治体系,以确保每名伤员都能在挽救生命所需的时间内得到充分的救治。起初,美国军方并未意识到这一体系的重要性,在没有完善的创伤救治系统的情况下,开始了伊拉克及阿富汗战争[5]
伊拉克战争爆发后,美国陆军卫生局局长于2003年底派遣创伤专家约翰·霍尔科姆上校前往伊拉克,评估战场救治能力。约翰·霍尔科姆上校发现,战场上的医护人员基本能满足现场救护需求,并将需要进一步救治的伤员送到Ⅱ级救治机构,但问题是这些Ⅱ级救治机构的手术能力十分有限,无法满足救治需求。规模更大、救治能力更强的Ⅲ级救治机构虽然被部署在伊拉克各地,却未被纳入救治体系,导致大量伤员无法得到应有的充分救治。随后,军方意识到建立联合创伤救治体系的重要性,开始在伊拉克战场着手建立JTTS[6]
自2004年11月起,Ⅲ级救治机构开始被纳入美军战伤救治体系。大量医护人员被派往伊拉克的5个Ⅲ级救治机构,他们在救治伤员的同时,还统计了伤员病情、治疗及转归的相关数据。美军驻伊拉克军事医疗司令部在审查数据时仍发现一些不足之处,如伤病员未能获得最新、最有益的救治措施,或者未能分配至最佳的救治机构。为此,负责该项目的军医走访了所有的Ⅲ级救治机构,收集整理相关临床救治规范,制定成指南后下发至所有Ⅲ级救治机构。通过每日、每周、每月跟踪临床应用情况,分析数据报告,从而评判指南的执行情况,并验证治疗决策是否成功。JTTS的建立,极大地改善了伊拉克战场上美军伤病员的救治状况,伤病员可以及时、有效地得到转运,获得最佳的救治。在随后的阿富汗战争中,JTTS有效提升了战场伤病员的救治效率。
为了加快军事创伤系统的发展,2010年3月25日,美国陆军卫生局将JTTS与圣安东尼奥JTS合并,组建成美国陆军外科研究所的一个下属机构,形成一个整体,统称JTS,共同为美军战伤救治系统服务[6]
JTS由美国陆军卫生局直接管理。在第一层次,从国家层面,设置JTS主任办公室,下辖国防部联合创伤数据库、信息管理/技术部、教育培训部、流行病分析部、创伤系统发展部及质量/绩效改进部等部门,负责JTS的组织及实施,收集创伤数据,改进创伤救治质量。在第二层次,从战区层面,由中央司令部指挥,包括联合战场创伤数据库收集团队及各战区创伤系统。在第三层次,从部队层面,由联合战场创伤系统主任办公室指挥,包括地区医疗救治机构及后送机构等[7]
JTS的主要任务包括:(1)将伤病员救护数据录入联合创伤系统数据库;(2)通过联合创伤系统数据库评估救治效果并开展相关研究;(3)根据战场救护需求,制定并规范创伤救治流程,包括CPGs及战术战伤救治(tactical combat casualty care,TCCC)指南;(4)定期分析讨论伤员救护信息,指导各层级救治机构提高临床救治效能;(5)评估临床指南或新医疗装备的应用效果,及时准确地改进临床治疗;(6)开展创伤救护相关的教育、培训,确保救治过程的标准化[8-9]
JTS的主要目标包括:(1)确保医疗数据的连续性及完整性,在各层级救治机构中共享伤病员数据;(2)确保创伤救治过程遵循临床操作指南及标准操作流程;(3)分析战伤救治需求,指导科学研究,持续改进救治指南及医疗设备;(4)促进联合创伤系统在军队医疗机构及战地现场的普及;(5)提高战伤救治水平,尽可能降低伤病发生率及死亡率[8-9]
在伊拉克战场上,部署JTTS之后,每6个月就会有一批来自美国陆、海、空军的医护人员在圣安东尼奥美国陆军外科研究所接受JTS工作培训。这些人员在伊拉克战争及阿富汗战争中都发挥了重要作用。自2004年以来,JTS制定、实施、改进并发布了43个CPGs[6]
为了更好地向战伤救治提供决策,圣安东尼奥美国陆军外科研究所以数据库的形式储存伤员数据。美军主要依靠国防部创伤登记处(Department of Defense Trauma Registry,DoDTS)[既往也称联合战场创伤登记处(Joint Theater Trauma Registry,JTTR)]进行数据的收集、整理工作[10]。DoDTS的数据收集始于2003年,由美国陆军外科研究所汇总。自2007年10月起,为便于采集最新的数据,DoDTS开始直接在战场进行数据的收集及存储。目前在DoDTS数据库中已有超过13万条伤病员救治记录[11]
尽管美军在阿富汗及伊拉克战场的存活率已经达到历史最高水平,JTS的研究团队仍然在不断寻找新的突破点,以求进一步提升战伤救治效率。
从2015年开始,JTS每周举行一次电视电话会议,来自各个层级的救治人员在会议上共同学习、讨论并改进伤员救治事宜。随着军事创伤系统的日渐成熟,圣安东尼奥的JTS团队与战场的JTTS团队实际上是两个截然不同但相互依存的实体。圣安东尼奥JTS团队一方面运行着JTTR,通过分析数据、发布CPGs来指导一线救治;另一方面培训并部署位于战场的救治团队,并为他们在战场的活动提供业务支持。部署在前线的团队通过在战区医院收集数据、督导战区救治实践并推广CPGs,直接支持JTS效能的改进。此外,JTS实时监控着前线救治数据,评估伤员的预后转归情况,在每周的会议中讨论如何改进救治流程,不断完善CPGs,并通过一些新技术、新工具提升救治效果[12]。近年来,JTS还联合多部门的专家共同建立了战创伤死亡审查流程,并首次对美国特种作战司令部在2001—2018年间所有伤员的救治情况进行审查,从中总结经验教训,以期前瞻性地改进创伤救治系统,并尽可能减少可预防的战伤死亡[13-14]。与此同时,JTS下属的研究机构不断分析评判战伤救治的重点研究领域,寻找突破口并引领研究热点,促进战伤救治效率的不断提升。
2015年,美军战伤救护委员会(Committee on Tactical Combat Casualty Care,CoTCCC)确定并公布了一份“战伤救治十大优先研发清单”,这份清单已成为美国军地创伤研究人员研究方向的重要参照[15]。由于这份清单主要侧重于解决战伤现场救护及院前救治中存在的问题,对后续外科救治中存在的问题及挑战涉及较少,2019年,JTS下属的美军外科战伤救治委员会(Committee on Surgical Combat Casualty Care, CoSCCC)通过调查研究确定了人员配置、复苏及出血管理、疼痛/镇静/焦虑管理、手术干预、创伤评估等5个战伤外科救治的重点研究领域,同时根据评分高低,公布出“战伤外科救治十大优先研发清单”[16]。这些研究一方面有助于指导美国国防部制定研究计划、确定应给予优先资助的军事或民用研究新领域,另一方面极大地促进了美军战伤救治理论及技术的发展,使其一直走在世界最前沿。
战伤救治具有伤员批量发生、救治条件有限等特点,如何在短时间内将伤员分配至最佳救治机构是决定战伤救治效率的重要环节。JTS通过构建战时救治链,能够指导伤病员后送及医疗调度,尽快将伤病员送到合适的医疗救治机构接受适合的治疗,同时最大限度确保救治的完整性[17]。有研究发现,应用JTS后,伤病员由战场后送至美国本土医院接受救治的时间从越南战争时的45 d减少至阿富汗战争的4 d,从而使伤员能更快得到有效的治疗,提升了伤员的救治效率[12]
DoDTS汇总了所有战地创伤患者的数据,通过大数据分析,结合循证医学理念,决策者可以预测战伤救治的发展趋势,制定并完善CPGs。CPGs的应用可以针对特定损伤以最优治疗策略进行标准化的治疗,减少人为因素的干扰,确保救治行为的科学性及准确性。同时,循证医学的大量应用,更新了战伤救治理念,促进了新救治方法的临床应用,保证了救治效果[18]
DoDTS数据显示,创伤患者的低体温与不受控制的出血密切相关,并可增高伤死率。在伊拉克战争中,通过控制大出血,增加保温措施,使低体温的发生率从7%降至1%以下[19]。结合循证医学的证据,CPGs中制定了以损伤控制复苏为核心的战地医院综合救治策略,使大量输血伤员的病死率由32%降至20%,有效降低了危重伤病员的伤死率[20]
JTS依托伤病员数据库分析伤病员救治中存在的不足,通过定期培训、分析讨论,提升医护人员的战场救治能力[21]。院前创伤治疗以TCCC指南为基础,针对战场环境下的可预防性创伤开展院前创伤生命支持。院内创伤治疗以CPGs为基础,针对严重的可预防性致死创伤进行高级生命支持。对后送创伤伤员,由相应医疗机构对伤员进行适宜性评估,并在后送过程中给予最优生命支持护理。例如,在阿富汗战争及伊拉克战争中,美军前沿外科手术队发挥了重要作用,研究人员对JTS数据进行分析发现,进一步优化常用的手术或非手术操作流程、规范相应的干预措施、加强相关技能培训是提升前沿外科手术队救治效能的有效手段[22]。美军正是通过不断评估、指导、规范救治行为,确保了医护人员战场救治能力的持续增强。
美军通过JTS不断发现战伤救治中存在的不足,以战场为实验室加速技术研发,又以战场为试验场促进技术应用。美军专门成立了由陆军、空军、海军科研人员组成的联合战场伤员研究队,开展战伤救治项目研究[23]。在他们的推动下,先后有100余项技术或装备用于战场,提升了战伤救治的效果,这些贴近实战化的研究,加速了技术及装备的野战化速度。在联合战场伤员研究队的努力下,技术或装备初次试验到应用于伤员的时间从10年压缩到了1年[24]。为了保证前线的血液供应,贯彻损伤控制复苏的理念,美军开展了军队供血专项工程,先后在中东多地战地现场建立血液转运中心,接收并储存由美国本土运送的血液制品并快速转运到前线,使伊拉克战场上美军58个战地救治机构的用血得到充分保障。根据战场救护的需求,美军同时研发了新技术以保障血液制品的良好供应。如美军研制的“黄金1小时血液储存容器”,在有效保存血液制品的同时,可以方便携带至前线,确保伤员在伤后“黄金1小时”内能尽快得到输血。这种通过实战促进实战的方式成为美军战伤救治技术持续领先的一大保障[25]。
战创伤救治是一个涉及多兵种、多部门、多环节的系统工程。从美军JTS的创建过程来看,该系统的建立最初也是为了解决转运协调不到位、救治流程不顺畅的问题。因此,我军有必要从顶层制度上设立战伤救治管理机构,统筹调配救治力量,通过规范战伤救治链,明确各部门职责、分工及协作任务,使战伤救治体系更加顺畅;根据陆军、空军、海军作战的相同点及不同点,以军种战伤救治特点为出发点,有针对性地建立战伤救治机构,设计战伤救治链,发展特色救治技术;从实战的角度统筹安排基层卫生单位及医院机动卫勤分队的平时训练、战时配合问题;从可持续发展层面,加强战伤救治人才培养及学科建设,促进我军战伤救治体系的完善及进步。
伤病员数据统计在美军战伤救治体系中扮演着重要角色。通过对伤病员接诊、救治、康复全流程数据的跟踪,能够很清楚地判断救治流程是否顺畅,伤病员是否得到有效救治以及需要改进的地方。随着信息技术的发展,美军的数据采集由最初的电子表格汇总发展到目前的数据库实时录入,对于战伤救治体系的持续完善发挥了巨大作用[10]。当然,美军在战伤数据统计中也存在一些不足,如在伤员院前数据的采集上存在数据不完善、时间线不清晰、人员信息不准确等问题,影响了对伤员院前救治的评估与改进[26]
目前,我军尚无统一的伤病员数据系统,信息化建设有待加强。在目前循证医学的大背景下,我军一方面可以借鉴外军现有的经验发展战伤救治技术,另一方面由于我军编制、装备的差异,更需要结合自身数据,以实战需求为导向,发掘战伤救治的突破点。军队伤病员信息数据库的规范化建设及有效分析利用,将有助于制定并优化创伤实践指南,促进战伤救治理论及技术的发展,更好地完善战伤救治体系。
美军联合创伤救治系统的一大特点是各级救治机构人员每周通过电视电话会议学习、讨论战伤救治中存在的问题及不足,持续改进救治流程。在以问题为导向的激励下,美军的战伤救治理论及技术快速得到更新,并通过定期学习传达给每一名救护人员,从而大大提升了救治效率。
目前,我军的战伤救治技术相对陈旧,更新速度较慢,尤其在一些基层卫生机构,战伤救治理论及技术长时间得不到更新。因此,有必要从实战角度出发,结合循证医学最新进展,参照我军平战时的实际需求,从全军层面制定统一的战伤救治技术训练科目及内容,定期开展战伤救治技术培训。通过加强对战伤救治技术理论的研究,及时将新理念、新技术传达给每一位官兵。同时重视创新战伤救治技术培训方法及培训模式[27],保证战伤救治的训练效果,切实为保障打赢做准备。随着目前信息化手段的加强,通过远程教学、多媒体教学等方法,可以对战伤救治技术进行规范,更有效地提升战伤救治效能。
创伤救治具有军民通用的特殊性。战伤救治系统及民用创伤救治系统具有相互促进的关系。以美国为例,在20世纪50年代,美国的民用创伤救治体系尚不健全,其后借助美军战时的成功经验逐渐建立了完善的民用创伤救治系统。到20世纪90年代,美军在总结海湾战争的经验教训时发现,美军战伤救治水平已经落后于民用创伤救治系统。鉴于此,美军开始参照民用创伤救治系统的经验,着手建立联合创伤救治系统。我军长期处于相对和平的环境,对战伤救治多停留在理论阶段,缺少实战经验,但创伤救治军民通用的特点使我们能够通过平战结合、军民融合的方式促进战伤救治系统的跨越式发展。首先,近年来我国民用创伤救治理论及技术进展迅速,形成了大量符合我国国情的指南或专家共识,可以转化为具有我军特色的战伤CPGs,指导战时创伤救治。其次,军队医疗机构可以借助其医疗优势,建立区域性创伤救治中心,积极参与地方应急医疗处置、灾害救援等,在实践中不断检验自身的救治效能。此外,可以在平时建立由军地多部门参与的创伤救治联合指挥中心,推动军地创伤救治资源整合,一方面对伤员救治进行协调指挥和专业指导,另一方面适时组织应急医疗演练,以此提高战场或突发公共事件中批量伤病员救治的指挥效率,更好地服务于平时及战时卫勤保障。
与美军比较,我军实战经验较少,战伤数据匮乏,一定程度上阻碍了创伤救治系统的发展。但是,我国每年仍有大量创伤患者,如何从这些患者的救治中为战伤救治系统的发展提供经验值得深入研究。具体措施包括:通过军队与地方的协作交流,从民用创伤救治系统中获取创伤救治的第一手资料,不断改进并优化战伤救治系统;在日常医疗活动及抗震、抗疫、救灾等非军事斗争行动中,不断检验并优化军事创伤系统的可用性,保持系统活力,确保战伤救治系统招之能用;通过不断的平战结合、军民融合,使我军战伤救治系统成为军民生命安全强有力的保护者。
  • 广州市科技计划(201704020157)
  • 广东省自然科学基金(2019A1515010978)
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2021年第46卷第10期
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doi: 10.11855/j.issn.0577-7402.2021.10.17
  • 接收时间:2021-01-27
  • 首发时间:2025-12-19
  • 出版时间:2021-10-28
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  • 收稿日期:2021-01-27
  • 修回日期:2021-05-30
基金
Science and Technology Program of Guangzhou(201704020157)
广州市科技计划(201704020157)
Natural Science Foundation of Guangdong Province(2019A1515010978)
广东省自然科学基金(2019A1515010978)
作者信息
    1南部战区总医院重症医学科,广州 510010
    2南部战区总医院质量管理科,广州 510010

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2种不同金属材料的力学参数

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属数
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genus
种数
Number of
species
占总种数比例
Percentage of
total species (%)

Genus
种数
Number of
species
占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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