STAGE TREATMENT — the system of medical and evacuation providing
field army or the population (in Civil protection) providing a combination of delivery of health care by the struck (patient) and their treatments with medical evacuation at an inevitable partition of process of treatment on stages of medical evacuation.
The term «stage treatment» is for the first time offered by V. A. Oppel in 1915. Emergence E. l. it was caused by the fact that in the past, including World War I, evacuation struck and patients, not coordinated to medical process, adversely affected outcomes of wounds and diseases. As shows historical experience, forms and methods of medical and evacuation providing (see System of medical and evacuation providing) troops in the conditions of fighting extents of development of arms of armies and methods of warfare, from the level of development of military and medical science and a condition of health care changed depending on social and economic conditions. However in the analysis of the forms applied in the past and methods of medical and evacuation providing existence of two opposite directions clearly came to light. The first of them was characterized by the aspiration to treat struck in fight and patients in close proximity to the area of fighting (so-called system of treatment on site); the second, on the contrary, provided carrying out broad evacuation struck and patients in the back, out of borders of the area of fighting (evacuation system).
The system of treatment was on site applied more often in wars of the past. The outcome of these wars was quite often turned in one, so-called decisive battle. Troops then had weak fire power, acted in slow-moving linear fighting orders. Means of communication, and also vehicles were imperfect. Troops sustained rather small sanitary losses. Diagnostic methods and treatments were still quite primitive. In these conditions evacuation struck and patients was applied seldom. To their thicket treated in the medical institutions developed in close proximity to the field of battle, sometimes in the next villages and the cities at local population.
Certainly, use of system of treatment on site completely conforms also to modern requirements of the medical science which established that rest is one of the major conditions defining in some cases a favorable outcome of a disease (defeat). However use of treatment on site in wars of the past was based not on the specified requirements of the medical science which was on quite low level at all. This system was applied because the nature of fighting and size of sanitary losses did not cause the necessity to resort to broad evacuation.
In the subsequent in connection with growth of number of the troops which are involved in war, improvement of arms, bigger maneuverability of fighting and that the main thing, significant growth in sanitary losses, use of system of treatment on site became harder and harder. There was a need to evacuate the majority struck and patients to the back, is farther from the area of direct fighting. Still N. I. Pirogov well understood need of evacuation. He stood up that in the medical institutions located near areas of fighting constantly there was enough free beds for free placement again arriving struck and patients that could be provided only with carrying out systematic evacuation. In the conditions of modern wars the health service is forced to resort to evacuation as well because medical aid stations and medical institutions of field army should work in a zone of influence of weapon of the opponent that threatens being on treatment of repeated defeat. It is necessary to add to it that placement of a significant amount it is heavy oops razhenny and sick troops in the next back has an adverse effect on their fighting, holds down their maneuverability, distracts a large number of forces and means from performance of operational tasks for protection of medical institutions. At the same time improvement of vehicles and means of communication (emergence of cars, railway transport, airplanes and so forth) provides a possibility of broad evacuation struck and patients. Therefore evacuation struck and patients in the war should be considered as a forced, but inevitable action in modern conditions.
In order that to refer evacuation to number of forced actions, there is also other important circumstance. It adversely influences the course of defeats and diseases not only in connection with disturbance of rest, but also because in the course of transportation evacuated inevitably pass through several medical aid stations and the hospitals removed on considerable distance from each other. This circumstance excludes a possibility of continuous overseeing by the struck (patients) and their treatments for the beginning of defeat (disease) before recovery by the same medical personnel, does not allow to exercise daily control, to reveal all changes during pathological process, to have the correct judgment of efficiency of the applied methods of treatment. Adverse influence of a partition of medical care and treatment is demonstrated by the following example. H. N. Burdenko during the studying of medical documents of 2500 wounded in World War I established that in process of advance on stages of evacuation from this number within the first two days of 585 wounded 3 times, 673 — 4 times, and 420 — even 5 times were tied up. Certainly, such unfairly frequent bandagings, as well as a partition of process of treatment in the absence of due interaction between stages of medical evacuation, not only did not promote success of treatment, but also could lead to serious consequences during wounds (diseases).
The negative impact of a gap between evacuation and treatment especially clearly was shown at the organization of medical support of the Russian army during World War I. Experience of practical work as the chief surgeon Yugo-Zapadnogo, and then the Northwest front allowed
V. A. Oppel to come to a conclusion about need of elimination of such gap. He wrote in 1915: «For the battlefield evacuation is inconceivable without treatment as treatment of wounded is impossible without evacuation. Both of these acts able to seem, at first sight, even diverse, actually are closely connected with each other and shall go in parallel... The only exit keeping interests of wounded and satisfying to interests of armies is development of a question as I would dare to be expressed, stage treatment...».
Speaking on April 16, 1916 at the Pirogovsky congress «on vrachebnosanitarny questions in connection with a mustache -
loviya of the present» with the report on «The organization of the surgical help to wounded in the near and far back of field army», V. A. Oppel opened an essence of the system of stage treatment offered them:
Fig. Scheme of stage treatment: I \according to V. A, Oppel (1915 — 1917); II \by the end of the Great Patriotic War of 1941 — 1945 *
«... under it... I mean such treatment which is not broken by evacuation and which it enters as an indispensable component. From the point of view of stage treatment the wounded receives surgical benefit where in this grant there was a need. The wounded is evacuated immediately as soon as it allows his health...». At the same time it is necessary to emphasize that V. A. Oppel in Manual for medical institutions, evacuation points and sanitary trains of the area subordinated to the Commander-in-chief of armies of the Southwest front, specified that «evacuation of wounded is regulated, from the medical point of view, the following data: conditions of military events, the nature of wounds, complications during wounds, cash of the pilot surgical help», i.e. it connected the volume and content of the surgical help at implementation of stage treatment with conditions of a military situation.
Further V. A. Oppel concretized problems of the surgical help in relation to fundamental units of medical and evacuation system of the period of World War I which were defined by it as
the advanced, intermediate and rear surgical belts (see the scheme). At the same time he considered that depending on «purely military circumstances, i.e. the nature of battles», the maintenance of «private hirur-gicheski-tactical tasks» cannot but change. However the principles of stage treatment which are put forward by V. A. Oppel at all their progressiveness were not applied in practice of medical support of pre-revolutionary Russian army. It was not succeeded to realize also some of the principles of stage treatment, included in «The instruction on the organization of the surgical help to wounded at the front», to N. A. Velyaminov, to-ry it was appointed in 1917 the chief field health inspector of the Russian army. Interfered with it the economic backwardness of Russia which caused low level of health care in the country extremely weak technical equipment of health service, and also persistent aspiration of the highest to
a mandovaniye to consider evacuation of wounded and patients only as purely military action. Especially it is necessary to emphasize that at that time evacuation struck and patients the military chiefs who do not have medical education and, therefore, illiterate treatments in questions preferential directed (see Medicine military).
The conditions providing use of the principles E. l., i.e. a combination of treatment to evacuation, arose in system of medical and evacuation providing field army only after Great October socialist revolution when for the first time in the history of domestic military medicine organizational and administrative functions including the organization of evacuation of wounded and patients were assigned to health service. However difficult and the adversity of the first years of development of the Soviet military medicine caused by civil war and difficulties of recovery of the destroyed national economy after its termination interfered with implementation of this opportunity in full. Only in the late twenties E. l. it was officially regulated as system of medical and evacuation providing Red Army in wartime by the joint order PBG of the USSR and the National commissariat of health care of RSFSR, the Crimea «The guide to sanitary evacuation in RKKA» (1929) became effective. The system of stage treatment as it was specified in this management, unites all actions for providing optimum conditions for recovery battle-scarred and sick by rendering timely and rational medical care and placement to them them on medical institutions, and also removals from areas of fighting. These two processes organizationally connected in a single whole cannot be separated one from another and cannot, without harm for all medical and sanitary business, be considered separately one from another. The management defined also main «stages of sanitary evacuation» (see Stages of medical evacuation) — the medical aid stations and medical institutions developed on the ways of evacuation for rendering different types of medical care struck and the patient and their further treatment. At that time treated these types of the help: «the first medical», «initial medical», «surgical, mainly urgent», «qualified surgical».
Essential contribution to further development of the theory E. l. B. K. Leonardov brought. He specified on neob-
a hodimost of a partition (echeloning) of medical care in field conditions, on obligation of consecutive and successive medical actions, performance to-rykh allows to carry out E successfully. l. struck and patients, and for the first time raised a question of expediency of transition from «drainage» type of evacuation (from a stage on a stage) to «evacuation to destination» (see Evacuation medical). The principle of evacuation was to destination regulated in the «Charter of military public health service of RKKA (the army area)» entered by the order PBG of the USSR in 1933. The charter demanded: «... transportation of patients and struck in fight shall not be made in the mechanical sequence from a stage on a stage; the fastest delivery of the patient and struck in fight on that stage of evacuation where evacuated the qualified medical care which is defined by the nature of a disease or defeat can be provided shall be continuous care of the sanitary chief». However the principle of evacuation formulated in the Charter to destination at all its progressiveness had no under itself appropriate organizational and material and technical resources yet. Rendering specialized medical care by the Charter was not provided though need for it was already predetermined clearly by the expressed differentiation of clinical medicine, especially surgeries, on a number of the industries (see. Specialized medical care).
Final completion of theoretical development and practical implementation of system E. h.p. evacuation to destination occurred on the basis of the analysis of experience of medical ensuring fighting of Red Army in the late thirties and during the Great Patriotic War of 1941 — 1945. This experience relying on progress of the Soviet health care created theoretical and material and technical resources for organizational registration of specialized medical care and consequently, and evacuation to destination struck and patients. Theoretical basis of system E. the h.p. evacuation to destination of the period of the Great Patriotic War was the uniform field medical doctrine formulated by E. I. Smirnov (see System of medical and evacuation providing), edges, in particular, provided uniform understanding of an origin and course of a disease, unanimity of views on methods of prevention and treatment of wounds and diseases, succession in holding medical actions at all stages of medical evacuation. During war stages of medical evacuation and their purpose, types of specialized medical institutions as a part of hospital bases, their tasks and volume of the given help, and also an order of evacuation to destination struck and patients finally were defined (see the scheme).
Philosophy E. the h.p. evacuation to destination defining its organization are: 1) the partition (echeloning) of the medical care provided at stages of medical evacuation, a cut provides establishment on each of them of a look and the volume of the help in strict accordance with conditions of a fighting, rear and medical situation; 2) the specialization of medical care in medical institutions of hospital bases allowing to make the most efficient use of achievements of medical science, shots of specialists doctors and special medical equipment for the benefit of effective treatment struck and patients; 3) succession of performance of medical actions at stages of medical evacuation, i.e. observance of the uniform methods of treatment struck and patients, systematic building at each subsequent stage of medical actions, an exception of their unnecessary duplication. It, in particular, is reached by medical sorting (see Sorting medical) and existence of short, accurate medical documentation (see Documentation medical); 4) timeliness of delivery of health care, first of all its urgent actions that is provided with bystreyshy delivery struck and patients on those stages of medical evacuation where medical care will be provided in the shortest terms and in full accordance with the nature of defeat (disease), and also the accurate organization of evacuation to destination; 5) the organic combination of actions for delivery of health care by the struck (patient) and to treatment with their evacuation, a cut not only represents the fundamental principle E. l. per se, but also provides successful functioning of all system of stage treatment with evacuation to destination in general. Respect for these principles substantially eliminates the contradictions stated above between evacuation and treatment and allows to reunite these two processes.
Principles E. h.p. evacuation to destination fully keep the value and in modern conditions. However emergence on arms of modern armies of means of mass defeat, new types of weapon and, as a result of it, change characterand and structures of sanitary losses (see), sharp increase in tension and maneuverability of fighting of troops, achievements of medical science — all this demanded entering of certain additions and specifications into an order and ways of implementation of the principles E. h.p. evacuation to destination at the present stage of its development. So, in the past types of medical care rather firmly were assigned to certain stages of medical evacuation: regimental medical aid station (see) — the first medical assistance, medical and sanitary battalion (see) — the qualified medical care (see) etc. In modern conditions there will be a situation at which the number struck and the patients needing this or that type of medical care inherent in this stage of medical evacuation will significantly exceed its opportunities. Therefore the modern system of stage treatment with evacuation to destination provides, as a rule, differentiation of actions of the first medical and qualified medical aid for urgency of their rendering and corresponding changes not only of the volume, but also a type of the medical care provided at this stage. For example, at mass receipt struck on regimental medical aid stations with it the first medical assistance only according to vital indications, and can be given in MSB (OMB) — generally the first medical assistance, and the qualified medical care — only according to vital indications. In these conditions the qualified medical aid in full is transferred to medical institutions of hospital base.
Modern system E. the h.p. evacuation to destination provides a number of the actions directed to the maximum restriction of multistaging in medical and evacuation process, the negative impact a cut clearly came to light during the Great Patriotic War. Treat the most important of these actions: rendering single-step exhaustive medical care; whenever possible early dispersal of the evacuation flows struck and patients between hospital bases by the maximum use modern to an evak atsionno-transpo rtny means, first of all — aviation; completion of treatment struck and the patients who are not subject to evacuation out of borders of the front in those hospital bases where they originally arrived (if it is not interfered by conditions of a situation);
evacuation struck and the patients sent for treatment to hospital bases of the back directly from those hospital bases of the front in to-rye they originally arrived.
One of important elements E. the h.p. evacuation to destination at the modern level of its development is the medical rehabilitation (see Rehabilitation in medicine) promoting return and to active work of the maximum number struck and patients in the shortest possible time. Importance of medical rehabilitation the cut, especially at the final stage showed experience of the Soviet medicine in the Great Patriotic War, in the course clearly, complex methods of treatment, for example in hospitals for lightly wounded were widely applied (see), the providing physical methods, physiotherapy exercises and labor therapy, and also were created hospital of a plastic surgery for treatment of seriously wounded.
Essential value for effective functioning E. the h.p. evacuation to destination, successful practical implementation of its principles has accurate management of all medical and evacuation process, a cut the corresponding chiefs (operating controls) of health service carry out. The main medical and evacuation actions are beforehand planned and displayed in the special section of the plan of medical support of a part, connection, association, in plans of work of bodies of managements of hospital bases. In a course of action (operation) necessary amendments according to the developing situation are introduced in plans (see Management of health service).
Stage treatment in Civil protection — system E. l., accepted by the health service of Civil protection (HSCP), close by the nature to similar system in the acting troops and coming from the basic provisions formulated and almost checked by medical service of Armed Forces of the USSR in the period of the Great Patriotic War of 1941 — 1945. At the same time features of operating conditions of MSGO define its differences (see. Health service of Civil protection). Treat them: a conclusion of medical institutions in a country zone for the purpose of their preservation and creation by it of the corresponding conditions for work; mass character and contemporaneity of emergence of sanitary losses among the population; impossibility of rendering exhaustive medical aid struck and the patient and their hospital treatment in the affected city in connection with considerable destructions, the fires and radioactive infection of the territory at nuclear explosion or infection with toxic agents and means of bacteriological weapon at use by the opponent according to chemical or bacteriological weapon (see the Center of mass defeats). Experience of Hiroshima and Nagasaki, undergone atomic bombing by Americans in 1945 visually testifies to the last. According to «The report of medical commission on studying of victims of atomic explosions in Hiroshima and Nagasaki», in Hiroshima during atomic attack 2/3 buildings were destroyed and on the area of 11,5 sq.km there were fires; in Nagasaki more than 37% of buildings were destroyed or damaged; the medical forces and means which were available in these cities suffered huge losses. In Hiroshima 90% of doctors and 75% of paramedical staff were killed or hard struck, most medical institutions was affected by a shockwave and the fires; from 45 municipal hospitals only in three it was possible to place struck. In Nagasaki nearly 50% of the doctors living in the city were killed or hard struck; the university clinic in which there were 75% of all hospital beds of Nagasaki is put out of action. Thus, the situation does not allow to enter medical institutions into the affected city and forces to be limited only to input of forces and means sufficient for first aid.
In connection with the told MSGO at emergence of the centers of mass losses in the back of the country will organize and performs two-stage treatment struck with their evacuation to destination. Groups of first aid (see Group of first aid) will be the first such stage, to-rye are developed around the center of mass losses with problems of evacuation of the first medical assistance and the organization of their further evacuation struck from the center, rendering to them in the developed in a country zone, hospital base (see), edges is the second (completing) stage of medical evacuation where struck there is a specialized and qualified medical aid.
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