13-从第 2 级医疗机构向第 3 级医疗机构进行空中医疗后送期间的战斗伤员管理英文

Downloaded from <a href="https://academic.oup.com/milmed/article/189/5-6/e1003/7421932bygueston27June2024">https://academic.oup.com/milmed/article/189/5-6/e1003/7421932 by guest on 27 June 2024</a>Management of Combat Casualties during Aeromedical Evacuation from a Role 2 to a Role 3 Medical FacilityActive Duty, Col Joseph K. Maddry, MD, USAF, MC<img src="/media/202408//1724832301.808081.png" /><img src="/media/202408//1724832301.822871.png" />*,†,‡,§;Allyson A. Araña, PhD*;Alejandra G. Mora, MS*;Active Duty, LTC Steven G. Schauer, DO, MC, USA†,‡,§;Lauren K. Reeves,MsPH*; Julie E. Cutright, BSN, RN*; Joni A. Paciocco,ADN, RN*;Crystal A. Perez, BSN, RN*;Active Duty, Maj William T. Davis, MD, USAF, MC*,†,‡;Active Duty, Maj Patrick C. Ng, MD, USAF, MC*,†ABSTRACTIntroduction:Emergent clinical care and patient movements through the military evacuation system improves survival. Patient man- agement differs when transporting from the point-of-injury (POI) to the first medical treatment facility (MTF) versus transporting from the Role 2 to the Role 3 MTF secondary to care rendered within the MTF, including surgery and advanced resuscitation. The objective of this study was to describe care provided to patients during theater inter-facility transports and compare with pre-hospital transports (POI to first MTF).Materials and Methods:We performed a retrospective chart review of patients with the Role 2 to the Role 3 transports in Afghanistan and Iraq from 2007 to 2016. Data collected included procedures and events at the MTF and during transport. We compared the intra-theater transport data (Role 2 to Role 3) to data from a previous study evaluating pre-hospiital transports (POI to first MTF).Results:We reviewed the records of 869 Role 2 to Role 3 transport patients. Role 2 to Role 3 transports were longer in duration compared to POI transports (39 minutes vs. 23 minutes) and were more likely to be staffed by advanced personnel (nurses, physician assistants, and physicians) (57% vs. 3%). The sample primarily consisted of military-aged males (mean age 27 years) who suffered from explosive or blunt force injuries. Procedures performed during each phase of care reflected the capabilities of the teams and locations. Pain and cardiac events were more common in POI evacuations compared to the Role 2 to Role 3 transports, but documentation of respiratory events, hemodynamic events, neurologic events, and equipment failure was more common during the Role 2 to Role 3 transports. Survival rates were slightly higher among the Role 2 to Role 3 cohort (98% vs. 95%, difference 3% [95% confidence interval of the difference 1-5%]).Conclusions:Inter-facility transports (Role 2 to Role 3) are longer in duration, transport more complex patients, and are staffed by more advanced level provider types compared to transports from POI.INTRODUCTIONThe Department of Defense medical personnel are tasked with determining how to stabilize combat casualties when*United States AirForce En route Care Research/59th Medical Wing/Sci- ence &amp; Technology, JBSA Lackland Air Force Base, TX 78236, USA† Department of Emergency Medicine, Brooke Army Medical Center, JBSA Ft. Sam Houston, TX 78234, USA‡ Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD 20814, USA§ US Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX 78234, USA2022 Military HealthCare Symposium, 2022 Special Operations Medical Associations, and 2022 Society for Academic Emergency Medicine.The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Air Force, Department of the Army, Department of Defense, or US Government.doi:<a href="https://doi.org/10.1093/milmed/usad404">https://doi.org/10.1093/milmed/usad404</a>Published by Oxford University Press on behalf of the Association of Mil- itary Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.a Military Treatment Facility (MTF) with surgical capabili- ties is not available for up to 72 h after the time of injury.1,2 To address this challenge, it is necessary to understand the capabilities, such as damage control and stabilization inter- ventions, required to ensure the survival of a patient long enough to reach a definitive level of care. In combat oper- ations, patients with traumatic injuries require urgent clin- ical care and expeditious evacuation to improve survival.3 Ground medics deployed in the field are often the first respon- ders but have limited capabilities and supplies. Aeromedical evacuation platforms such as U.S. Army Medical Evacuation (MEDEVAC) allow for urgent evacuation to Role 2 or Role 3 facilities that provide higher levels of care. MEDEVAC transport times may vary depending on environmental factors and the ability to land in combatant locations.4 Previous data have shown that longer transport times are associated with increased morbidity and mortality.5–7During the conflicts in Iraq and Afghanistan, the imple- mentation of Secretary Gates’ “golden hour” policy resulted in the establishment of multiple dispersed Role 2 militaryMILITARY MEDICINE, Vol. 189, May/June 2024e1003Downloaded from <a href="https://academic.oup.com/milmed/article/189/5-6/e1003/7421932bygueston27June2024">https://academic.oup.com/milmed/article/189/5-6/e1003/7421932 by guest on 27 June 2024</a>TABLE I. Definitions of Eventstreatment facilities.7 This policy enforced the rapid transport of combat casualties to damage control surgery andresusci- tation.7 With this forward surgical capability came the need to transport post-operative combat casualties from the Role 2 MTFs to the more advanced Role 3 MTFs. The MEDE- VAC system was designed predominately for the evacua- tion of casualties from the field of combat and pre-surgical trauma management.8Those patients transported from a Role 2 to a Role 3 following damage control surgery and/or resuscitation are significantly different from those transferred from the point-of-injury (POI). To address this difference, the U.S. Army has intermittently supplemented the standard paramedic-based MEDEVAC with critical care flight nurses, though not consistently.9Conversely, the U.S. AirForce Criti- cal CareAir Transport Team (CCATT) consisting of an emer- gency medicine or critical care physician, an emergency or critical care nurse, and a respiratory therapist functions as a “flying Intensive Care Unit” and has been employed in Role 2 to Role 3 inter-facility transports.10 However, CCATT pre- dominately functions within fixed-wing aircraft, so they are usually limited to transport from Role 2s established at or near an airfield.Staudt et al. evaluated data from the JTS database and described patients treated at a Role 2 and subsequently evac- uated to a Role 3 in Afghanistan.11 This study provided a description of patient characteristics and the en route care personnel but did not abstract data from the individual flight medical records or evaluate patient outcome data. The authors advocated for future studies to evaluate the care provided dur- ing Role 2 to Role 3 MTF transports as well as short- and long-term outcomes based on en route care provider skill level. Accordingly, we conducted a study describing the inter- ventions performed during aeromedical evacuation from a Role 2 to a Role 3, the aeromedical evacuation team per- forming the transport, and the association with 30-day patient outcomes.MATERIALS AND METHODSThe Strengthening the Reporting of Observational studies in Epidemiology guidelines were used to confirm proper report- ingof our observational study (SDC 1). We conducted a retro- spective review of medical records of U.S. military, U.S. gov- ernment employees, and U.S. contractors who were treated at a Role 2 facility and subsequently evacuated to a Role 3 MTF in Iraq or Afghanistan from January 2007 to December 2016. We excluded patients under the age of 18 years, detainees, and those who died before departing the Role 2 facility.We queried the Department of Defense Trauma Registry to identify patients that met our inclusion criteria. We then obtained these patients’ MEDEVAC or CCATT patient care records from the Joint Trauma System or CCATT Pilot Unit. We also queried the Joint Trauma System Role 2 Database to determine the procedures performed at the Role 2 facilities and the Department of Defense Trauma Registry for outcome data. Trained research team members abstracted the data fromEvacuation of Combat Casualties, Role 2 to Role 3<table><tr><td colspan="2">Event type Definition</td></tr><tr><td>PainRespiratoryHemodynamicCardiacNeurologicalRenal/urinaryTemperatureEquipment failureAbnormal lab</td><td>Increase in rate or dose of existing analgesia Start of new analgesiaA documented complaint of painAs determined by medical provider to include: Headache,chest, abdominal, back, hip, leg/knee,arm/shoulder, muscle painAs documented by medical provider to include:SpO2≤ 90%FiO2 increase &gt;10%O2L min increase &gt;4≥5 increase in PEEPAs documented by medical provider to include: SBP ≤90 or ≥180 or 20% change from baseline MAP ≤65 or ≥120 or 20% change from baseline CVP change from baseline of 5HR &lt;60 bpm or &gt;120 bpm or 20% change frombaselineAs determined by medical provider to include: Cardiac arrestNotable findings on electrocardiogramAs determined by medical provider to include:Agitation, seizures, change in mental status, motor, cognitive, or sensory abilityAs determined by medical provider to include:Oliguria (low urine output), dark urine, renal calculusFever (body temperature ≥ 100.5 F or 38 C)Hypothermia (body temperature &lt; 95 F or 35 C) As determined by medical provider to include: Propaq failure, battery failure, ventilator failure Glucose (&lt;70 or &gt;105)Potassium (&lt;3.5 or &gt;5)Sodium (&lt;136 or &gt;145)PTT (&gt;35)</td></tr></table>SBP, systolic blood pressure; MAP, mean arterial pressure; CVP, cen- tral venous pressure; HR, heart rate; PTT, partial thromboplastin time. Definitions from Maddryetal.10these charts and entered them into an electronic database. These records included demographic data, injury description, provider type, flight dates and times, transport time, clinical data (vital signs, laboratory values if available, procedures, medications, and events), and 30-day survival. Clinical events were identified from the provider narrative and descriptions of events in the patient care records using criteria from our pre- vious studies (Table I).10 We implemented quality assurance measures to ensure consistency among the trained abstractors, including a secondary review of 100% of records.12,13In addition to the data collected specifically for this current study, we used data from a previously published paper describing patients traumatically injured in combat in Afghanistan and evacuated from the POI by MEDE- VAC.8That study, which included 1,237 patients transported between January 2011 and March 2014, contained similar variables to this current dataset. We used the tables and figures from the previous paper to calculate summary data (frequen- cies, percentages, means, and standard deviations) to comparee1004 MILITARY MEDICINE, Vol. 189, May/June 2024Downloaded from <a href="https://academic.oup.com/milmed/article/189/5-6/e1003/7421932bygueston27June2024">https://academic.oup.com/milmed/article/189/5-6/e1003/7421932 by guest on 27 June 2024</a>Evacuation of Combat Casualties, Role 2 to Role 3TABLE II. Patient and Provider Characteristics<table><tr><td>Variable</td><td>Role 2 to Role 3(n = 869)</td><td>POI to 1st MTFa(n = 1,237)</td><td>Difference (95% CI)</td></tr><tr><td>Age, years</td><td>27 (7)</td><td>24 (5)</td><td>−3 (−4 to −2)*</td></tr><tr><td>Male gender</td><td>97%</td><td>99%</td><td>−2% (−3% to −1%)*</td></tr><tr><td>Highest provider type</td><td></td><td></td><td></td></tr><tr><td>Paramedic</td><td>8%</td><td>21%</td><td>−13% (−16% to −10%)*</td></tr><tr><td>Medic</td><td>14%</td><td>76%</td><td>−62% (−58% to −65%)*</td></tr><tr><td>Advanced**</td><td>57%</td><td>3%</td><td>54% (51% to 58%)*</td></tr><tr><td>Not specified</td><td>20%</td><td>	</td><td>	</td></tr><tr><td>Injury severity score</td><td>13 (13)</td><td>14 (14)</td><td>−1 (−35 to 2)</td></tr><tr><td>ISS ≤10</td><td>57%</td><td>50%</td><td>−7% (−11% to −3%)*</td></tr><tr><td>ISS 11-19</td><td>21%</td><td>25%</td><td>−4% (−8% to −1%)*</td></tr><tr><td>ISS 20-29</td><td>12%</td><td>14%</td><td>−2% (−5% to 1%)</td></tr><tr><td>ISS 30-75</td><td>11%</td><td>12%</td><td>−1% (−4% to 2%)</td></tr><tr><td>Injury type</td><td></td><td></td><td></td></tr><tr><td>Blast</td><td>42%</td><td>69%</td><td>−27% (−32% to −23%)*</td></tr><tr><td>Blunt</td><td>29%</td><td>2%</td><td>27% (24% to 30%)*</td></tr><tr><td>Penetrating</td><td>27%</td><td>28%</td><td>−1% (−4% to 4%)</td></tr><tr><td>Burn</td><td>2%</td><td>1%</td><td>1% (0% to 2%)</td></tr><tr><td>Flight time, minutes</td><td>39 (20)</td><td>23 (56)</td><td>−16 (−19 to −13)*</td></tr></table>Values are mean (standard deviation) or percent of sample.*Differences are statistically significant if the 95% confidence interval of the difference does not include zero.**Advanced provider category included registered nurses, physician assistants, and physicians.aPOI to 1st MTF data are from Maddryetal.characteristics, medications, events, and outcomes of patients transported from the POI (the previous study) and those trans- ported from a Role 2 to a Role 3 (current study). We used independent t-tests to analyze continuous variables and chi- squared tests for nominal variables. Outcomes are reported as differences with 95% confidence intervals; results are consid- ered statistically significant if the corresponding confidence interval does not include or cross zero. We conducted all anal- yses in SAS version 9.4 (SAS Institute, Cary, NC, USA).RESULTSWe analyzed data from 869 patients transported from a Role 2 to a Role 3 MTF between January 2007 and December 2016. The most common originating facilities were Shank (33%), Jalalabad (16%),and Ghazni (11%). Patients were transported to one of five Role 3 facilities: Bagram (76%), Kandahar (14%), Bastion (10%), Balad (&lt;1%), and Baghdad (&lt;1%). The mean flight time from a Role 2 to a Role 3 was 39 min, which was significantly longer than the mean flight time from the POI to the first MTF (Table II). Most from Role 2 to Role 3 transports were staffed by advanced providers (RNs, PAs, physicians) and medics; in contrast, flights from the POI cohort were primarily staffed by medics and paramedics. Most patients transported from a Role 2 to a Role 3 were young men with an average age of 27 years. Nearly half of the sample suffered from an explosive injury, over half had an injury severity score (ISS) of 10 or less, and the mean injury severity score ISS was 13. Although the patients trans- ported from the POI to the first MTF had a similar mean ISS, that cohort had a higher proportion of patients with explosiveinjuries and lower proportion of patients with blunt injuries and an ISS of 10 or less.The most common procedures conducted at each phase of care reflected the capabilities of each location and team (Table III). During transport from the POI to the first MTF, most procedures were related to damage control resus- citation, such as fluid/blood administration, hemorrhage con- trol, and hypothermia prevention. On the other hand, proce- dures at the Role 2 MTF were more advanced and included imaging (X-ray and ultrasound), intubation and mechani- cal ventilation, fluid/blood administration, laparotomy, fas- ciotomy, and amputation. Patients were more likely to require ventilator management and receive medications (Table III) during the inter-facility flight from the Role 2 to the Role 3 compared to the initial flight from the POI.Pain and cardiac events were more commonly documented in POI evacuations compared to the Role 2 to Role 3 trans- ports (Fig. 1). Conversely, documented respiratory events, hemodynamic events, neurologic events, and equipment fail- ure were more common during the Role 2 to Role 3 transports. Survival rates were slightly higher among the Role 2 to Role 3 cohort compared to the POI cohort (98% vs. 95%, difference 3% [95% confidence interval of the difference 1% to 5%]).DISCUSSIONIn our study evaluating the transport of patients from a Role 2 to a Role 3 facility, we found significant differences from the early transport phase from the POI to a MTF. First, the Role 2 to Role 3 transports were significantly longer in duration due to the dispersal of Role 2s close to combat operations per Secretary Gates’ “golden hour” policy. Second, the majorityMILITARY MEDICINE, Vol. 189, May/June 2024e1005Downloaded from <a href="https://academic.oup.com/milmed/article/189/5-6/e1003/7421932bygueston27June2024">https://academic.oup.com/milmed/article/189/5-6/e1003/7421932 by guest on 27 June 2024</a>Evacuation of Combat Casualties, Role 2 to Role 3TABLE III. Procedures and In-flight Medications during Each Phase of Care<table><tr><td>Transport from POI to firstMTF (n = 1,237)a</td><td>At Role 2 (n = 869)</td><td>Transport from Role 2 to Role 3 (n = 869)</td></tr><tr><td>Supplementary oxygen (49%)Any medications (30%)Analgesia (28%)Fluids (28%)Intravenous access (22%)Pressure packing (13%)Hypothermia prevention(11%)Spinal stabilization (6%)Intraosseous access (5%)Tourniquet (5%)Blood products (4%)Nasal/oral airway (3%)CPR (3%)Splint/sling (2%)Chest needle (2%)Intubation (2%)Sedation (1%)Hemostatic agent (1%)Chest seal (1%)Defibrillation (1%)Cricothyrotomy (1%)Chest tube (&lt;1%)</td><td>X-ray (89%)Intravenous access (78%)Fluids (70%)Hypothermia prevention(64%)Wound dressing/packing(61%)Ultrasound (60%)Stabilization/immobilization(52%)Drains (43%)Supplementary oxygen(39%)Mechanical ventilation(30%)Intubation (29%)Blood products (26%)Tubes (23%)Arterial line (16%)Central line (15%)Laparotomy (9%)External fixator (9%)Fasciotomy (9%)Chest tube (8%)Amputation (6%)</td><td>Hypothermia prevention (53%) Any medications (51%)Analgesia (44%)Supplementary oxygen (40%)Fluids (30%)Mechanical ventilation (29%) Stabilization/immobilization(26%)Sedation (24%)Paralytic (15%)Chest tube (7%)Antiemetic (6%)Blood products (4%)Vasopressors (3%)Tourniquet (1%)Wound dressing/packing (1%) Parenteral access (1%)Antibiotics (&lt;1%)</td></tr></table>aPOI to 1st MTF data are from Maddryetal.8of patient care teams included an advanced medical provider (physician, PA, or RN). Third, patients were more likely to require ventilator management and receive medications dur- ing transport. Fourth, patients were more likely to have doc- umented respiratory, hemodynamic, and neurologic events during transport. Finally, more teams documented equipment failure during the transport.Our study highlights the importance of ensuring medi- cal teams providing Role 2 to Role 3 transports possess the necessary knowledge and skills to address the differences from earlier phase transports from POI. Mabry et al. found improved survival of casualties transported by a paramedic versus a medic.4,14Apodacaetal. found physician-led British Medical Emergency Response Teams had similar outcomes to U.S. Army medics despite caring for casualties with higher ISSs.15,16 Conversely, Maddry et al. found no association between advanced en route care personnel and 30-day sur- vival, but theorized this was likely due to the brief trans- port duration following Secretary Gates’ golden hour pol- icy.8 Extrapolating the findings of these earlier studies to the results of our study suggest that advanced medical per- sonnel are necessary to ensure the survival of inter-facility transfer patients for multiple reasons. First, our study found inter-facility transports were of significantly greater dura- tion where the use of physicians and nurses is likely toyield greater benefit. Second, inter-facility en route care personnel had to manage mechanical ventilators, medication infusions, paralytics, chest tubes and other advanced medical equipment and procedures outside of the standard medic’s scope of practice. Finally, inter-facility transfer patients had a higher incidence of documented respiratory events, hemody- namic events and neurologic events. These events are similar to those encountered and managed by emergency department and intensive care unit personnel.17,18 Conversely, ground medics and corpsmen are more focused on the initialstabiliza- tion as opposed to the on-going critical care after stabilization. Training medics to assume these duties is challenging, and potentially unrealistic. The time required to train and main- tain these skills as well as the necessary clinical experience present significant challenges.The current events in Ukraine highlight the importance of ground transport of combat casualties. Given the lack of con- tinuous air superiority within Ukraine, rotary-wing aircraft are at significant risk of enemy attack and do not provide a con- sistent transport solution as occurred in Operation Iraqi Free- dom/Operation Enduring Freedom (OIF/OEF).19While Spe- cial Operations Command possesses specialized physician led teams capable of evacuating casualties and the military has supplemented evacuation teams with nurses, physicians, and physician assistants, the majority of conventional U.S.e1006 MILITARY MEDICINE, Vol. 189, May/June 2024Evacuation of Combat Casualties,Role 2 to Role3Downloaded from htps:/academic.oup.com/mimedlaricle/189/5-6/e1003/7421932 by guest on 27 June 2024<img src="/media/202408//1724832302.1096802.jpeg" />FIGURE 1.Comparison of inlightevents betweenfights from the point of injury (POI)or aRole l facility (solid black bars)vs.lights from aRole 2 toa Role 3 facility (shaded gray bars).IPOI to lst MTF data are from Madry et al.⁸*Comparisons were statistically significant atP&lt;0.05.military ground evacuation transport teams lack physician, PA,and nursing support.20 Future studies should evaluate the ability of CCATT,MEDEVAC,and other military med- ical teams to provide ground transportation.This includes the ability to provide evacuation using both military and civilian vehicles of opportunity lacking electrical power,oxygen,and other capabilities provided by some military aircraftLimitationsOur study has several limitations.First,this is a retrospec- tive chart review and our findings may be limited as a result ofincomplete ormissing data.Specifically,the task demands on transport providers vary by phase of transport and may result in different documentation practices for Role 2 to 3 transports compared to transports from POI.The use ofdata abstractors has the potential for subjectivity;however,thor- ough chart abstraction,substantive abstractor training,and quality review procedures were implemented to limit sub- jectivity.12,13 Second,variations in documentation practices between MEDEVAC and CCATT units may impact consis- tency of the data within the Role 2 to 3 cohort.Third,while this study found significant differencesbetween the transports from POI and the transports between facilities,we cannot assert any causality with regards to outcomes.With regards to external validity,this study focused on military traumapatients during OIF/OEF and our results may not be gener- alizable to the civilian community or other conflicts.Civilian patients and casualties in future military conflicts may have significantly different traumatic injuries and medical ailments than those discussed in our studyCONCLUSIONWhen compared to MEDEVACtransports from the POI,inter- facility transports within theater (Role 2 toRole 3)are longer in duration and utilize more advanced level provider types to transport patients of higher complexity.Military medical planning,training and resource allocation should consider these factors,to include increasing the number of advance medical personnel trained in aeromedical evacuation,when preparing for future military operationsACKNOWLEDGMENTSNone declared.CLINICALTRIAL REGISTRATIONNot applicable.IRB HUMAN SUBJECTThis study was reviewed and approved by the 59th Medical Wing JBSA Lackland IRB as a minimal risk human subject study.MILITARY MEDICINE,Vol.189,May/June 2024e1007Downloaded from <a href="https://academic.oup.com/milmed/article/189/5-6/e1003/7421932bygueston27June2024">https://academic.oup.com/milmed/article/189/5-6/e1003/7421932 by guest on 27 June 2024</a>Evacuation of Combat Casualties, Role 2 to Role 3INSTITUTIONAL ANIMAL CARE AND USECOMMITTEE (IACUC)Not applicable.INDIVIDUAL AUTHOR CONTRIBUTION STATEMENTJ.K.M.: Principal Investigator, obtained funding, designed the study, drafted, and edited the manuscript. A.A.A.: assisted with study design, performed statistical analysis, and provided critical revision of the manuscript. A.M.: assisted with study design and performed statistical analysis. S.G.S.: drafted and edited the manuscript. L.K.R.: abstracted data. J.C.: abstracted data. J.A.P.: abstracted data. C.A.P.: acquisition of data, conducted quality control, and edited the manuscript. W.T.D.: edited and provided critical revision of the manuscript. P.C.N.: edited and provided critical revision of the manuscript.INSTITUTIONAL CLEARANCEThe manuscript was reviewed and cleared for dissemination by the Clini- cal Investigations and Research Support, 59th Medical Wing/Science and Technology.FUNDINGDefense Health Agency Research and Engineering Directirate Intramural J9, Grant number J917EC02.CONFLICT OF INTEREST STATEMENTAll authors have no conflicts of interest to disclose.DATA AVAILABILITYThe data underlying this article will be shared on reasonable request to the corresponding author.REFERENCES1. Schauer SG, Long BJ, Rizzo JA, et al: A conceptual framework for non-military investigators to understand the joint roles of med- ical care in the setting of future large scale combat operations. Prehosp Emerg Care 2023; 27(1): 67–74. <a href="https://doi.org/10.1080/10903127.2021.-2008070">10.1080/10903127.2021.</a> <a href="https://doi.org/10.1080/10903127.2021.-2008070">2008070</a>2. 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13-从第 2 级医疗机构向第 3 级医疗机构进行空中医疗后送期间的战斗伤员管理 英文

13-从第 2 级医疗机构向第 3 级医疗机构进行空中医疗后送期间的战斗伤员管理英文