NEJM述评：从波士顿爆炸案看急救医疗服务体系
看到丁香园一个非常好的帖子，转过来与大家分享。前言：波士顿马拉松爆炸案已经过去2周了，作为生活在波士顿，哈佛医学院旁的我，可能比诸位战友有更多的感受，也在其中感受到了美帝强大的急救和公共安全解决能力。事发后，NEJM和Lancet也做了一系列的述评文章，从医学从如何更好处置突发事件出发 ，希望能对诸位战友有所裨益。
4月15日下午2点50分，在第一位跑者完成波士顿马拉松后3 小时左右，两枚炸弹炸响，造成 3人死亡，260多人受伤。 旁观者起初非常恐慌，但很快他们开始帮助那些伤者，而不是继续处于恐慌之中。执法机构和紧急医疗服务（ EMS ）人员迅速集中到了现场。在几分钟内，救护车开始将收到严重致命伤的伤员转运到最近的医院。
波士顿在此次爆炸案中的快速有效应对得到了很多医生的赞誉。尘埃落定之后，我们也应当分析这一事件教给了我们什么。
第一、1%的低死亡率归功于以下六个方面
1、波士顿是一个具有七个创伤中心和多个世界级的医院的城市（可以在附录上找到城市医疗中心分布）。波士顿的急救人员将爆炸案的伤者分发到这个地区的所有医疗中心，每个中心都得到了合适的伤员数目。
2、虽然美国大多数城市的护理人员没有治疗过炸弹袭击受害者。但是，波士顿院前及院内医疗提供者都接受过冲击波损伤的基础护理和紧急救援的培训。
3、爆炸的当天是州立节日（爱国者日），这座城市的手术室和其他临床机构没有满员运行。
4、爆炸发生时间为下午三点左右，这是当地医院医生换班的时间。因此，医疗机构的管理人员和两班的医疗护理人员都严阵以待。
5、爆炸时马拉松比赛正在进行，那里已经部署了大量的警员，安全人员及医疗急救人员。
6、作案人员是在户外引爆的爆炸设置。如果爆炸发生在一个密闭空间（例如房屋，巴士或者火车），这会产生更多的冲击损伤（例如肺冲击伤）和死亡人数。户外爆炸在一定程度上减少了受害者数目。
第二、现场照片反应了旁观者在最初应对大规模杀伤性事件中发挥了重要作用
未受伤的现场人员没有逃离现场，而是脱下他们T恤并将其作为止血带或者是直接压在伤口上控制出血。其他旁观者拔出了路边的护栏，方便将受伤者运出，并迅速转移到创伤中心。有医疗训练经验的旁观者和跑者开始对伤员进行分类。这些勇敢的平民是真正的第一时间反应人员。
第三，自发行为并非偶然
1、准备紧急事件应急预案：精心设计的灾难预案目的就是提供一个紧急快速执行的行为框架。这样的框架对于确保突发大规模杀伤性事件后的良好协调反应来说十分必要。爆炸案件紧急医疗事故中医疗人员的快速有效响应和理想状态相差无几，因为他们非常清楚自己要做什么。
2、进行严格的医疗培训：那些并不清楚自己该怎么做的人，只要跟着带头人去做就是了。这就是所谓“仪式化”灾难应急预案是如何起作用的。我们应该效仿以色列的学说，既强调国家协调的重要性，标准操作程序，不断关注最大收治能力，避免急诊科的过度拥挤，根据类型和严重程度的进行伤者的分类，高强度地进行严格训练。正是因为波士顿遵循了这么多的准侧，它才可以有效应对突发事件。
3、做好全面预防灾害的准备：波士顿的反应说明了全面预防灾害准备的价值算在。在9/11之后的最初几年和紧随的炭疽攻击事件，联邦预防的效果集中体现在生物恐怖主义和大规格杀伤性武器方面。最近，联邦机构的预防范围更加广泛。
4、将预防准备工作纳入日常流程：医院能提高其预防能力的最好途径是建立强大的医疗服务体系。
当我们回顾波士顿的紧急医疗救援时，仅仅列举它的好是不够的。我们必须知道为什么它的反应会这么好。否则，一些市民也许会错误地认为，就算急诊科拥挤，就算缺乏灾难预案和严格的训练，他们的医务人员也能应付自如。
Lessons from BostonArthur L. Kellermann, M.D., M.P.H., and Kobi Peleg, Ph.D., M.P.H.April 24, 2013DOI: 10.1056/NEJMp1305304 At 2:50 p.m. on April 15, nearly 3 hours after the first runner completed the Boston Marathon, two blasts ripped through the crowd that was gathered along the approach to the finish line, killing 3 people and injuring more than 260. Within moments, the crowd's initial panic was replaced by purposeful action, as bystanders ran to, rather than from, the horror to help the injured. Law-enforcement and emergency medical services (EMS) personnel swiftly converged on the scene. Within minutes, ambulances began transporting the most critically injured to nearby hospitals.
Once victims reached Boston's hospitals, the story continued in the same vein. Noted Harvard surgeon and author Atul Gawande described how quickly they arrived and how “everything happened too fast for any ritualized plan to accommodate.”1 Praise for Boston's rapid and effective response is richly deserved. Clearly, lives were saved. But before memories fade, we should analyze the event for the lessons it offers. Although a formal after-action report will take time, enough is known for us to offer some initial observations.First, the remarkably low mortality rate of the attack — 1% — was attributable in part to excellent care and in part to six factors that favored the rescuers:
• The bombing occurred at a major event where large numbers of police, security, and EMS personnel were already deployed.
• Because it was race day — indeed, a state holiday — it is likely that the city's operating rooms and other clinical services were running at less than full capacity.
• The attack happened shortly before the 3 p.m. change of shift at area hospitals. As a result, a full complement of administrative staff and two shifts of health care providers were on site at each facility.
• The bombs were detonated in a city that is home to seven trauma centers and multiple world-class hospitals (see map in the Supplementary Appendix, available with the full text of this article at NEJM.org). Boston EMS personnel wisely distributed casualties among the area's trauma centers, so each one received a manageable number.• The bombers detonated their relatively low-yield devices out-of-doors. A bombing inside a closed space (e.g., a building, bus, or train) produces more primary blast injuries (e.g., blast lung) and fatalities, because surrounding walls concentrate blast waves.2 The absence of structural collapse facilitated the swift extrication of victims.• Although most health care providers in the United States have never treated a bombing victim, lessons learned by military surgeons, emergency physicians, and nurses in Iraq and Afghanistan are progressively percolating through the trauma care community. Moreover, hundreds of Boston's prehospital and hospital-based responders had already learned the basics of blast-injury care and the operational challenges their city could face. In 2009, Rich Serino, then Boston's EMS chief and now deputy administrator of the Federal Emergency Management Agency, hosted the first citywide “Tale of Our Cities” conference in Boston, at which doctors from India, Spain, Israel, Britain, and Pakistan who had managed the consequences of terrorist attacks explained the nature of the blast injuries they treated, the triage systems they used, and other lessons responders can use to save lives. More than 750 locals attended.3 Second, photographs taken shortly after the bombings vividly depict the vital role bystanders play in the initial response to mass-casualty incidents (see photohttp://www.nejm.org/na101/home/literatum/publisher/mms/journals/content/nejm/0/nejm.ahead-of-print/nejmp1305304/20130426/images/small/nejmp1305304_f1.gifBoston Marathon, April 15, 2013.). Instead of fleeing the scene, runners tore off their shirts and either used them as tourniquets or applied direct pressure to control bleeding. Other bystanders pulled racecourse barriers aside to facilitate access to the victims and their rapid extrication to area trauma centers. Bystanders and runners with medical training started triaging victims. These courageous civilians were the true first responders.Third, the seemingly spontaneous actions Gawande describes didn't happen by chance. The goal of a well-crafted disaster plan is to provide a framework for preconsidered action. Experience has shown that such a framework is necessary to ensure a well-coordinated response to a sudden mass-casualty event. Boston's health care providers reacted the way they did because they knew what they were supposed to do. Those who did not were smart enough to follow the lead of those who did. That's how a “ritualized” disaster plan works.
What is not clear is whether other U.S. cities, if faced with a challenge of similar magnitude, would have done as well. In contrast to Israel, a country that has ample experience with terrorist bombings, too many U.S. hospitals treat disaster preparedness as an afterthought. We would be wise to emulate Israel's doctrine, which emphasizes the importance of national coordination, standard operating procedures, constant attention to surge capacity, the avoidance of emergency-department overcrowding, the distribution of casualties according to type and severity, and the frequent conducting of rigorous drills.4 Because Boston followed many of these principles, it mounted an effective response. Our goal must be to ensure that every U.S. city can do the same.5 Finally, Boston's response illustrates the value of adopting a broad-based approach to disaster preparedness. In the early years after 9/11 and the anthrax attacks that followed, federal preparedness efforts were too narrowly focused on bioterrorism and weapons of mass destruction. More recently, agencies have embraced a more flexible, all-hazards approach, as exemplified by the National Health Security Strategy first published by the Department of Health and Human Services (DHHS) in 2009,5 the Department of Homeland Security's Quadrennial Homeland Security Review published in 2010, and a monograph from the Centers for Disease Control and Prevention entitled “In a Moment's Notice: Surge Capacity for Terrorist Bombings” (released 2007, updated 2010).The best way hospitals can prepare is to base their response on a strong foundation of daily health care delivery.4 The $347 million in federal funding allocated to the DHHS's National Healthcare Preparedness Program cannot, by itself, transform our $2.8-trillion-per-year health care industry; the economics don't work. Therefore, it is vital that hospitals weave the threads of preparedness into their daily routine.As we reflect on Boston's response, it's not enough to enumerate what went well; we must understand why. Otherwise, some citizens and health care professionals may erroneously conclude that it doesn't matter if emergency departments are crowded and if disaster plans and rigorous drills are lacking, because their hospital's medical staff will simply “rise to the occasion.” That's a risky bet. The Red Sox benefitted from some lucky breaks in the 2007 World Series, but their victory was largely due to preparation, teamwork, and execution. The same was true when the city of Boston was attacked on April 15. The rest of us should take that lesson to heart.
应对突发事件，我们需要学习的东西有很多。 我觉得最重要的是要加强国民的素质教育，遇到灾难的时候不能只顾自己逃命，要有团结意识，要有爱心，教会大家不要因为突发事件而再发生踩踏事件，不要给伤员们雪上加霜，也不要再增加受伤人数。现在很多孩子都是独生子女，性格里都有自私的成分，所以国民素质教育要从孩童抓起。另外医院要加强应急预案的培训，让每一位上岗人员都有最专业的抢救能力，这样就能将伤亡人数降低，将损失降低。其实并非国外的东西都好，但我们不得不承认，国外的很多东西确实值得我们学习和借鉴，取长补短。中国人，醒醒吧！ 看后很感慨！我们需要学习的还有很多很多！谢谢分享！
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