外军卫勤研究系列讲座(4)苏军408医院在切尔诺贝利核事故中的医学救援

苏军408医院(现为乌克兰军队基辅军区医院,以下简称408医院)驻地距离切尔诺贝利核电站115 km.该医院曾参与了切尔诺贝利核电站事故伤员医疗救治工作.现将有关情况介绍如下.     

苏军408医院在切尔诺贝利核事故中的医学救援

苏军408医院（现为乌克兰军队基辅军区医院，以下简称408医院）驻地距离切尔诺贝利核电站115km。该医院曾参与了切尔诺贝利核电站事故伤员医疗救治工作。现将有关情况介绍如下。     

医院船参加海洋灾害医学救援的实践与思考

本文介绍了由医院船周围若干舰船及直升机担负救治转运任务,将海洋灾害伤员及时运送至医院船主平台进行救治,使得从灾害发生至展开救援的时间显著缩短,为抢救危重伤员赢得宝贵时机的实践经验,认为医院船在海洋灾害救援及战伤救治中能够发挥独特的重要作用。     

核辐射事故的分级救治

核事故医学应急是整个应急工作的重要组成部分。其主要任务是对受照射人员进行及时、正确的医学处理,最大限度地减少人员伤亡和远期危害,有效地保护公众的安全与健康。为解决核辐射事故后的医学救援问题,ＩＡＥＡ提出了有关建议,推荐了有关伤员的医学应急处理原则和一般程序[1,2]。欧美一些发达国家在建立核事故医学应急的体制机构方面积累了不少先进经验[3,4]。我国也已经建立了比较完整的核事故医学应急救援体系,并且开展了一系列医学应急准备工作。本文简要介绍了严重核辐射事故后分级救治的基本原则、一般任务和组织机构。一、分级救治…     

切尔诺贝利核电站事故受照人员的急性辐射效应

切尔诺贝利核电站事故使工作人员受到反应堆释出的放射性物质等辐射因素的综合作用,使受照人员因大剂量照射引起一系列急性辐射效应。本文从诊断方法、临床表现、剂量估算、采取措施等方面作了详细介绍。     

汶川大地震中伤员阶梯救治原则探讨

目的 探讨阶梯救治原则在地震灾害紧急医疗救援中的应用价值和方法改进.方法 对参加四川汶川大地震的现场医疗急救、前方医院和后方医院的医疗工作进行总结分析.结果 现场救治伤员4 689例次,处置危重伤员413例,完成清创术等各类手术197例,3例重伤员死亡,开放伤口感染率近80%;前方医院收治伤员1 400多例次,完成手术200台次,抢救危重伤员110例次,截肢率3.0%,伤口感染率66.8%;后方医院为125例伤员开展了1-5次/部位的确定性手术治疗,术后无医院感染,无死亡,无截肢.结论 阶梯救治原则是重大自然灾害批量伤员救治的基本原则,急救人员应尽早开展现场急救;后送力量是保障救治成功率的重要因素,完善伤票制度能显著提高救治效率;前方医院主要开展生命支持、创面处理和简单骨折的救治工作;确定性专科治疗应在后方医院进行.     

“5.23”铁路脱线事故伤员救治——解放军184医院救治铁路事故伤员纪实

2010年5月23日凌晨2点10分,因山体滑坡,由上海开往桂林的K859次旅客列车在江西省余江附近发生脱线事故,造成大量人员伤亡。驻江西省鹰潭市的解放军184医院立即启动紧急预案,第一时间到达事故现场,对事故伤员进行了成功救治,彰显了军队医院和人民军医的优良作风。这次铁路事故伤员救治特点：一是反应迅速。接到求援电话后,医院立即出动多辆救护车和多名医务人员赶赴事故现场,是第一家到达现场救援的医院。     

生物剂量估算技术在核与辐射事故医学救援中的应用

核与辐射事故医学救援中,对事故人员进行分类诊断可使医疗资源得以充分利用,从而大大提高救援效率。生物剂量估算技术是目前判断外照射放射损伤程度的有效方法。利用生物剂量估算技术进行受照人员的分类诊断,对核与辐射事故医学救援的高效、有序具有重要意义。该文针对现有生物剂量估算技术的特点及其在核与辐射事故医学救援分类诊断中的应用进行了分析讨论。     

汶川地震德阳地区伤员医疗救治的分析与研究

目的 分析汶川地震中伤员的伤情特点、救治过程和效果,探讨灾难救援中信息侦察、军事化救援、损害控制原则的应用和作用.方法 收集了四川省德阳市某医院在2008年5月12日～5月31日收治的1420地震伤员资料,分析各部位伤发生率和各年龄组受伤情况,回顾早期救治分类、救治方法和内容.结果 1420例伤员中,共有1821处损伤,单个部位伤1089例,占76.69%;多部位伤331例,占23.31%;四肢损伤、体表和软组织损伤多于其他部位损伤;单个部位伤明显多于多部位伤(P<0.01).伤员流在震后前2天最多,占68.80%,明显多于其他时间(P<0.01);19～45岁年龄组伤员多于其他年龄组(P<0.01);伤后12小时以上才得到救治的伤员最多(P<0.01).结论 平时灾难救援中救治的速度是关键,信息侦察是保证早期灾害救治的前提;在救治中应遵循损害控制原则,平时加强自救互救训练和急救知识培训可挽救更多伤员的生命,军事化救援是今后灾害救援的新趋势.     

后方医院参与汶川地震医疗救援的行动策略

汶川地震医疗救援包括对地震灾区伤员的医疗救助、重建灾区医疗单位救治能力和补充医疗人员.后方医院应当在震后迅速采取行动,派出医疗分队前伸到灾区参与前线的医疗救助,快速建立区域性地震伤员救治网络,启动院内救治系统,积极收治伤员.在救命治伤的同时,不能忽视对伤员的人文关怀.     

从病理学角度看切尔诺贝利核事故的医学生物学后果

本文根据病理形态学特征提出了对切尔诺贝利事故所致小剂量/剂量率受害者疾病分类的方法,指出了尸检研究中应注意的问题,从8个方面的症状表现核事故中青年救援者多器官疾病对加速机体老化的证明及指出了它在生物医学上的意义,提出了小剂量/剂量率技术事故殃及的三种组织或细胞成分的可能机制及其后果,重点分析了基辅地区居民甲状腺小泡性滤泡瘤的病理学形态改变的特点.     

乌克兰居民在切尔诺贝利核电站事故后的健康状况

本文报告了切尔诺贝利事故后受到影响的乌克兰三个人群(救援人员、30km区域内撤离人员、儿童和少年)在1990～2004年间健康状况的观察结果.受害者的总人数有22.5万人.受照剂量在0.25～0.70Gy的救援人员有7 400人.观察的指标有随机性效应(甲状腺癌、白血病、妇女乳腺癌和其他恶性肿瘤的发病率)和确定性效应(急性放射病、白内障、非肿瘤性疾病,以及儿童和少年的健康状况),证明上述人群中这些效应的危险性有所增加.报告还分析了非照射因素在这些效应发生中所起的作用,说明这些疾病在发病原因上的多样性.     

美军核医学应急救援力量建设特点分析

核医学应急救援作为军队的重要任务成为各国加强建设的重点,美武装部队在核医学应急救援力量建设方面积累了成熟经验。本文重点分析美军在核应急救援中的法律地位和作用、职能任务及核应急救援力量建设特点、现状,以期对我军核医学应急救援力量建设有所启示。     

Notfallbergung bei Unfall an HDR-Afterloading-Anlagen

PROBLEM: HDR brachyradiotherapy has minimized the exposure to radiation of the personnel working in this field. Nonetheless there are periodically reported troubles with afterloading units concerning the retraction of sources that require immediate action for the limitation of possible damage. LEGAL PRINCIPLES ACCORDING TO THE GERMAN REGULATION CONCERNING PROTECTION AGAINST RADIATION (STRAHLENSCHUTZVERORDNUNG = STRLSCHV): If in afterloading brachyradiotherapy the radiation source remains extended through malfunction we deal with an emergency according to the StrlSchV. The rescue personnel should be chosen in accordance with section 50 StrlSchV (Table 1). ORGANIZATION OF THE RESCUE OF THE PATIENT: The quickest possible rescue of a patient in an emergency demands an unequivocal definition of responsibilities. Our recommendations in this instance: the physicist is responsible for the organization of the emergency rescue. The radiation oncologist in charge informs himself about the necessary emergency measures before starting the treatment and carries out the emergency rescue. If the physicist diagnoses a failure in the retraction of the source he tries to remove the failure. If he doesn't succeed in retracting the source the radiation oncologist carries out the rescue of the patient. The organizational structure of the clinic allowing, the emergency physician should invariably be the physician who placed the applicator. In the emergency rescue the radiation oncologist should be protected by a lead barrier (Figure 1, Table 2) and use manipulators (Figure 1). DOSE ASSESSMENT IN PERSONNEL AND PATIENT: The radiation exposure of the rescue personnel is calculated from the photon-equivalence dose HX with the help of the dose-rate constant of 192Ir (Table 3). According to the same procedure there can be evaluated the local radiation exposure of the patient concerned (Table 3). CONCLUSIONS: Generally speaking, all considerations regarding the topic of emergency rescue should always start out from a worst-case scenario. Of all the people involved the patient is the one who is most exposed if the radiation source is located inside his or her body. If an emergency rescue is necessary the radiation exposure of patient and personnel can only be minimized by a quick rescue. This end requires a properly equipped emergency workplace, good training of all the people concerned, and regular exercises of the rescue procedures. A well-practiced emergency management can be of life-saving importance for the patient.     

汶川地震救援中某部官兵患病情况分析

 目的 为预防灾难救援相关疾病提供参考依据,以提高部队执行灾害救援任务时的卫勤保障能力.方法 选取自2008-05-19至2008-07-16汶川地震灾区某部医院收治的部队官兵,采用国际疾病分类方法( ICD-10) 对疾病进行统计分类,并计算各系统疾病构成比.结果 执行救援任务期间,该部队官兵共就诊1190人次,各系统疾病均有发生,其中皮肤和皮下组织疾病构成比为31.01%,呼吸系统疾病、外伤和消化系统疾病构成比分别为28.32%、13.53%和9.83%.皮肤和皮下组织疾病、呼吸系统疾病、外伤、消化系统疾病、口腔耳鼻喉疾病在救援期(＜15 d)和重建期(≥15 d)的发病差异具有统计学意义(P<0.05).结论 抗震救灾官兵的疾病谱呈现多元性.要根据不同疾病的不同特点和规律选择有效的防治措施,确保救援和卫勤保障有效.     

汶川地震伤员医疗救治模式的探讨

目的 探讨汶川地震灾难救援中,军事医学救援的作用和地位.方法 收集了四川省德阳市某医院在5月12日～5月31日收治的1420例地震伤员资料.分析伤情特点、早期军事医学救援的方法、内容及效果.结果 1420例中,共有1821处损伤,单个部位伤1089例(76.69%),多部位伤331例(23.31%).单个部位伤明显多于多部位伤(P<0.01);四肢损伤、体表和软组织损伤多于其它部位损伤(P<0.01);伤员流在震后前2天最多(68.80%),明显多于其它时间(P<0.01);对968例伤员进行了分类分检;伤后12小时以上才得到救治的伤员最多(P<0.01).结论 军事医学救援应在地震后24小时内快速展开,对规范救治秩序、保证批量伤员救治有效进行将起到重要作用,"德阳模式"探索了一种军事医学救援的重要方法,军事医学救援足今后灾难救援的新趋势.     

Radiation exposures of cancer patients from medical X-rays: how relevant are they for individual patients and population exposure?

X-ray procedures have a substantial impact not only on patient care but also on man-made radiation exposure. Since a reliable risk-benefit analysis of medical X-rays can only be performed for diagnosis-related groups of patients, we determined specific exposure data for patients with the ten most common types of cancer. For all patients with the considered cancers undergoing medical X-ray procedures in a maximum-care hospital between 2000 and 2005, patient- and examination-specific data were retrieved from the hospital/radiology information system. From this data, the cumulative 5-year effective dose was estimated for each patient as well as the mean annual effective dose per patient and the mean patient observation time for each cancer site. In total, 151,439 radiographic, fluoroscopic, and CT procedures, carried out in 15,866 cancer patients (age, 62 ± 13 years), were evaluated. The mean 5-year cumulative dose varied between 8.6 mSv (prostate cancer) and 68.8 mSv (pancreas cancer). Due to an increasing use of CT scans, the mean annual effective dose per patient increased from 13.6 to 18.2 mSv during the 6-year period. Combining the results obtained in this study for a particular hospital with cancer incidence data for Germany, we estimated that cancer patients having X-ray studies constitute at least 1% of the population but receive more than 10% of the total effective dose related to all medical X-ray procedures performed nationwide per year. A large fraction of this dose is radiobiologically ineffective due to the reduced life expectancy of cancer patients.     

Current problems in medical support for provision of radiation and chemical safety in the Armed Forces

The events and changes of the last decade, appearance of new factors determining the character of professional activities of military doctors have become the cause of displace of some accents in organization of medical support of RF AF radiation and chemical security. The possibility to use chemical and radiation factors for military ends as well as wide spread of chemical substances and sources of ionizing radiation in human everyday activities during peacetime allow to confirm that protection of subject, society and state is closely connected with support of radiation and chemical security. Considerable widening of class of problems standing before medical service and their increased complexity make impossible medical support of radiation and chemical security of the RF AF staff with forces and means of specialists working only in one field (toxicologists-radiologists). Such complex problem requires the conduction of scientifically well-founded, effective measures based on the knowledge of specific effects of radiation and chemical factors on human body.     

A cytogenetic approach to the effects of low levels of ionizing radiations on occupationally exposed individuals

The aim of the present study was to assess occupationally induced chromosomal damage in hospital workers exposed to low levels of ionizing radiation. Thirty-two interventional cardiologists, 36 nuclear medicine physicians and 33 conventional radiologists were included in this study, along with 35 healthy age- and sex-matched individuals as the control group. We used conventional metaphase chromosome aberration (CA) analysis, cytokinesis-block micronucleus (MN) assay as important biological indicators of ionizing radiation exposure. Occupational dosimetry records were collected over the last year (ranged from 0.25 to 48 mSv) and their whole life exposure (ranged from 1.5 to 147 mSv). The results showed significantly higher frequencies of dicentric and acentric CAs (p < 0.001) and MN (p < 0.01) in all exposed groups than in the controls. Taking all the confounding factors into account, no obvious trend of increased chromosomal damages as a function of either duration of employment, exposed dose, sex or age was observed. Interventional cardiologists had the highest rates of CA and MN frequencies between the worker groups, though the differences were not significant. These results indicate that long term exposure to low dose ionizing radiation could result in DNA damage. Hence, the personnel who work in the hospitals should carefully apply the radiation protection procedures.