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,http://www.77cn.com.cnrgeareasofthecountry,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@http://www.77cn.com.cn.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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