伤员转运后送
01-从角色2向角色3医疗设施航空医疗后送期间的战斗伤亡管理
03-Collective aeromedical evacuations of SARS-CoV-2-related ARDS patients in a military tactical plane- a retrospective descriptive study
04-乌克兰火车医疗后送的特点，2022
02-Decision Support System Proposal for Medical Evacuations in Military Operations
02-军事行动中医疗后送的决策支持系统建议
05-无人驾驶飞机系统的伤员疏散需要做什么
04-Characteristics of Medical Evacuation by Train in Ukraine, 2022.
05-Unmanned Aircraft Systems for Casualty Evacuation What Needs to be Done
07-一个德语语料库，用于搜索和救援领域的语音识别
08-雷达人类呼吸数据集的应用环境辅助生活和搜索和救援行动
08-Radar human breathing dataset for applications of ambient assisted living and search and rescue operations
06-基于信息融合的海上搜索救援目标定位
07-RESCUESPEECH- A GERMAN CORPUS FOR SPEECH RECOGNITION IN SEARCH AND RESCUE DOMAIN
12-欧盟和世卫组织联手进一步加强乌克兰的医疗后送行动
09-战场伏击场景下无人潜航器最优搜索路径规划
11-麦斯卡尔医疗后送-康涅狄格州陆军警卫医务人员在大规模伤亡训练中证明了他们的能力
06-Target localization using information fusion in WSNs-based Marine search and rescue
13- 年乌克兰火车医疗后送的特点
09-Optimal search path planning of UUV in battlefeld ambush scene
10-志愿医护人员从乌克兰前线疏散受伤士兵
14-海上搜救资源配置的多目标优化方法——在南海的应用
14-A Multi-Objective Optimization Method for Maritime Search and Rescue Resource Allocation An Application to the South China Sea
15-基于YOLOv5和分层人权优先的高效无人机搜索路径规划方法
17-乌克兰医疗保健专业人员在火药行动期间的经验对增加和加强培训伙伴关系的影响
17-Ukrainian Healthcare Professionals Experiences During Operation Gunpowder Implications for Increasing and Enhancing Training Partnerships
15-An Integrated YOLOv5 and Hierarchical Human Weight-First Path Planning Approach for Efficient UAV Searching Systems
16-基于旋转变压器的YOLOv5s海上遇险目标检测方法
16-YOLOv5s maritime distress target detection method based on swin transformer
19-人工智能的使用在伤员撤离、诊断和治疗阶段在乌克兰战争中
19-THE USE OF ARTIFICIAL INTELLIGENCE AT THE STAGES OF EVACUATION, DIAGNOSIS AND TREATMENT OF WOUNDED SOLDIERS IN THE WAR IN UKRAINE
18-军事行动中医疗后送的决策支持系统建议
20-乌克兰医疗保健专业人员在火药行动中的经验对增加和加强培训伙伴关系的影响
20-Ukrainian Healthcare Professionals Experiences During Operation Gunpowder Implications for Increasing and Enhancing Training Partnerships
21-大国冲突中医疗后送的人工智能
18-Decision Support System Proposal for Medical Evacuations in Military Operations
23-伤亡运输和 疏散
24-某军用伤员疏散系统仿真分析
23-CASUALTY TRANSPORT AND EVACUATION
24-Simulation Analysis of a Military Casualty Evacuation System
25-无人驾驶飞机系统的伤员疏散需要做什么
26-Aeromedical Evacuation, the Expeditionary Medicine Learning Curve, and the Peacetime Effect.
26-航空医疗后送，远征医学学习曲线，和平时期的影响
25-Unmanned Aircraft Systems for Casualty Evacuation What Needs to be Done
28-军用战术飞机上sars - cov -2相关ARDS患者的集体航空医疗后送——一项回顾性描述性研究
27-乌克兰火车医疗后送的特点，2022
27-Characteristics of Medical Evacuation by Train in Ukraine, 2022.
28-Collective aeromedical evacuations of SARS-CoV-2-related ARDS patients in a military tactical plane- a retrospective descriptive study
03-军用战术飞机上sars - cov -2相关ARDS患者的集体航空医疗后送——一项回顾性描述性研究
30-评估局部现成疗法以减少撤离战场受伤战士的需要
31-紧急情况下重伤人员的医疗后送——俄罗斯EMERCOM的经验和发展方向
31-Medical Evacuation of Seriously Injured in Emergency Situations- Experience of EMERCOM of Russia and Directions of Development
30-Evaluation of Topical Off-the-Shelf Therapies to Reduce the Need to Evacuate Battlefield-Injured Warfighters
29-军事行动中医疗后送的决策支持系统建议
29-Decision Support System Proposal for Medical Evacuations in Military Operations
32-决策支持在搜救中的应用——系统文献综述
32-The Syrian civil war- Timeline and statistics
35-印尼国民军准备派飞机接运 1
33-eAppendix 1. Information leaflet basic medical evacuation train MSF – Version April 2022
36-战场上的医疗兵
34-Characteristics of Medical Evacuation by Train in Ukraine
22-空军加速变革以挽救生命：20年来航空医疗后送任务如何取得进展
34-2022年乌克兰火车医疗疏散的特点
33-信息传单基本医疗后送车
40-航空医疗后送
43-美军的黄金一小时能持续多久
42-陆军联手直升机、船只和人工智能进行伤员后送
47-受伤的士兵撤离
46-伤员后送的历史从马车到直升机
37-从死亡到生命之路
41-后送医院
52-印度军队伤员航空医疗后送经验
53-“地狱之旅”：受伤的乌克兰士兵撤离
45-伤病士兵的撤离链
54-热情的和资源匮乏的士兵只能靠自己
57-2022 年乌克兰火车医疗后送
51-医务人员在激烈的战斗中撤离受伤的乌克兰士兵
59-乌克兰展示医疗后送列车
61-俄罗斯士兵在乌克兰部署自制UGV进行医疗后送
60-“流动重症监护室”：与乌克兰顿巴斯战斗医务人员共24小时
50-医疗后送——保证伤员生命安全
阿拉斯加空军国民警卫队医疗后送受伤陆军伞兵
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2022 年乌克兰火车医疗后送的特点
战术战地救护教员指南 3E 伤员后送准备和要点 INSTRUCTOR GUIDE FOR TACTICAL FIELD CARE 3E PREAPRING FOR CASUALTY EVACUTION AND KEY POINTS
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北极和极端寒冷环境中的伤亡疏散：战术战斗伤亡护理中创伤性低温管理的范式转变
-外地伤员后送现场伤亡疏散
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从角色2到角色3医疗设施期间战斗人员伤亡管理
关于军事行动中医疗疏散的决策支持系统建议书
在军事战术平面上对sars-cov-2相关 ARDS患者进行的集体空中医疗后送： 回顾性描述性研究
2022年乌克兰火车医疗疏散的特点
透过战争形势演变看外军营救后送阶梯 及医疗救护保障措施
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组织紧急医疗咨询和医疗后送 2015 俄文
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2022年乌克兰火车医疗疏散的特点
  **原始调查：** **|全球健康状况** 2022年乌克兰火车医疗疏散的特点 斯蒂格 ·瓦拉文斯，医学博士；阿尔比娜 ·扎尔科娃，医学博士；安贾 ·德 ·韦格莱尔，医学博士，医学硕士；玛丽 ·伯顿，公共卫生硕士；让-克莱门特卡布罗尔医学 博士；詹姆斯S。李，医学博士，理学硕士 **摘要** 2022年的乌克兰战争严重影响了受冲突影响地区的患者获得医疗保健的机会，以及医疗后送的选 择有限。航空运输是战区医疗后送的一种常见方法，由于拥有飞机和地对空武器的两支现代化军 队发生冲突，因此不安全；因此，无国界医生与乌克兰铁路公司和乌克兰卫生机构合作，通过医 疗定制火车启动医疗后送来解决这一问题。 目的介绍旨在改善受战争影响的患者获得医疗保健服务的医疗后送列车的实施情况。  **本案例系列描述了乌克兰战争期间在一个冲突地区用于医疗后送的两列火车的改造。**这项研究于 2022年3月30日至11月30日进行。其中一列火车的调整最小，可以迅速部署，以解决最紧迫的人道 主义需求，而另一列火车则进行了重大的结构修改，以提供重症监护能力。该报告详细说明了列车 的医疗能力、转诊的组织以及所遇到的业务挑战。此外，它还包括一个关于最初8个月内运送的患 者特征的案例系列，基于常规收集的由医疗列车运送的所有患者的方案描述性数据。 结果8个月内，2481例患者（男女比例1.07，男性1136 [46%]，女性1058 [43%]；缺失数据，287 [12%]；中位年龄63岁[范围0-98岁]）从乌克兰冲突前线附近的11个城市撤离到安全地区。最初， 火车主要疏散创伤患者，但在战争过程中，患者的特征随着医疗和非急性情况的增加以及更少的创 伤患者而变化。进入重症监护病房车厢的主要原因是密切监测和观察，主要干预主要是呼吸衰竭。  **本研究的结果表明，在战区通过改装列车进行的医疗后送是可能的，并可以改善受战争影响的患者** **获得医疗保健的机会。**船上有重症监护能力，可以运送病情更严重或受伤的人员。然而， 目标人群 不应局限于创伤患者，因为受影响的保健机构拥有更广泛的人群，其疏散的需要和紧急性可能会随 着时间的推移而改变。  JAMA网络打开。2023;6(6) :e2319726.doi :10.1001/jamanetworkopen.2023.19726 **要点** 如何在战区实施医疗后送列车？可以期 待什么类型的病人？ 本病例系列描述了2022年乌克兰冲突 期间使用2列火车的医疗后送。 8个月后，医疗列车进行了74次旅行， 疏散了2481名病人 来自靠近前线的11个城市；在此期间 , 最常见的病人运输类型从与创伤相 关的伤亡转变为有医疗和非急性转诊 原因的病人。 这意味着本研究的结果表明，如果能够 适应当地条件和不断变化的患者群体， 在一个已存在铁路网的冲突地区，火车 医疗后送是可行的。 **+邀请的评论** **+补充内容** 作者的隶属关系和文章的信息是 在本文的最后列出了这些内容。 **开放访问。**这是在CC-BY许可条款下发布的一篇开放获取的文章。 JAMA网络打开。2023;6(6):e2319726.doi： 10.1001/jamanetworkopen.2023.19726（转载）2023年6月23日1/9 从詹姆斯工作下歉。由嘉宾将于20223年11月30日访问 **开放|乌克兰火车医疗疏散的全球健康特征，2022年** **介绍** 在2022年乌克兰战争一周年纪念日，乌克兰事务高级专员办公室的报告 人权组织报告有21580名平民伤亡，其中8101人死亡，并指出了实际数字 由于来自大多数被围困地区的信息很少，这可能要高得多。1访问 前线附近的安全和基本的医疗服务由于活跃而严重受损 武器化的战斗和有限的运输选择，由于路障，损坏的道路，和 倒塌的桥梁。医护人员逃离，数百个医疗设施遭到袭击，而 剩余的功能性医疗服务是创伤患者。2-4此外， 受影响地区最初的大规模撤离往往会留下老年人、病人或制度化的人 没有持续的护理，这迟早会使他们处于需要医疗治疗的情况下 疏散5-7 无国界医生组织（MSF）已经是一个独立的医疗人道主义组织 他探索了缓解过度拥挤的医院和带来冲突的方法 受影响的患者将被转移到更安全的地区。航空运输，最常被报道的医疗技术 在战区撤离，8由于两支现代化军队的冲突而不安全 飞机和地对空武器。此外，该领空已对民用飞机关闭。 由于长途跋涉、频繁的路障和更大的原因，公路疏散具有固有的挑战 需要人力和物质资源。然而，乌克兰的铁路系统最初只是这样的 受影响最小，允许将更多的病人运送到安全区域。 关于这种替代疏散方式的文献很少。最后一次大规模的战时医疗活动 在1950年至1953年的朝鲜冲突期间。9然而，最近， 法国火车将COVID-19患者送往重症监护病房（icu）。10 本研究描述了一个火车医疗后送计划，旨在改善获得 对战争影响患者的医疗保健。它报告了两列医疗用列车的改装， 包括1个ICU容量、人员配备、患者选择，列车路线选择，组织 推荐，和相关的操作挑战。此外，它还包括一个案例系列在 最初8个月运送的患者的特征、需要转诊和护理类型 如果 **程序说明** **列车适应** 无国界医生组织的医疗和后勤部门起草了可行性、技术和战略计划 咨询当地利益相关者。与乌克兰国家铁路公司合作，2 乌克兰制造的客运列车被改装，为医疗运输做好准备。改造 以在法国使用COVID-19列车的经验指导。10然而，战争和 需要考虑到当地的情况。 基本的医疗列车有最小的修改，并启动以迅速应对 最紧迫的人道主义需求。它由两节卧铺车厢组成，带有改进后的隔板 允许担架进入，1卧铺车厢为较轻的门诊病人，1 工作人员的马车。病人的同伴可以呆在上层床或无人居住的下床上。 火车配备了药物和材料，氧气浓缩器，吸盘，和 负责插管或胸部引流管的急救设备。多达32名固定病人和27名门诊病人 病人可以被转移。 虽然基本列车在2022年3月31日投入使用，建设更先进 具有ICU容量的医疗列车仍在进行中（e，见附录1中的图）。广泛的改造 进行了检查，修改了电气系统和剥离了内部以适应医院 床和设备。该列车由8节车厢组成：1节车厢和5张ICU病床，其中2节车厢可以乘坐 提供有创机械通气，2节车厢，9张床，1个常规车厢 卧铺车厢，1辆带床和床垫的车厢，适用于非重症患者 条件和他们的同伴。剩下的3节车厢是给工作人员、医疗用品、氧气用的 JAMA网络打开。2023;6(6) :e2319726.doi： 10.1001/jamanetworkopen.2023.19726（转载）2023年6月23日2/9  **开放|乌克兰火车医疗疏散的全球健康特征，2022年**  发电机，和一个不间断的电源，这是需要允许ICU的运输 病人在不可靠的电气电网上长途跋涉。氧气缸 故意不考虑，因为火车有长时间卡住的危险 铁路基础设施，在战区将具有高爆炸风险。产生氧气 系统可为每张ICU病床提供30 L/min的氧气，而2张ICU病床均有 机械通气能够提供60 L/min和2.8-6.0之间的恒压 呼吸机需要的铁棒。结构变化、技术改造和设备 先进医疗列车的安装花了23天，第一次部署是在4月24日， 2022.在列车部署后，该公司继续进行了微小的调整。空调被安装在了 弹簧，而氧气车厢配备了电加热和隔热 氧气管道的冬季温度，以保持氧气发生器的功能，这是谁 强调了能够在部署后进一步修改列车以作出反应的重要性 遇到的或预期出现的问题。 **列车工作人员** 除了少数无国界医生组织的国际工作人员外，被招募到工作人员中的主要是当地个人 火车。这些人都是有ICU经验的医生，护士，护士助理，技术后勤专家，和 一个翻译。员工的数量随着时间的推移而增加，允许更多的轮岗和更多的护士为每个 病人国际工作人员包括一名项目协调员、一名急诊/ICU医生和一名护士 经理，一旦高级列车启动，一名重症监护室的护士。当地的工作人员接受了培训 逐渐接管这些职位。乌克兰铁路公司的员工仍在负责日常事务 训练功能和运动。 **患者和列车的路线的选择** 在接受转诊时，需要考虑转诊病人的数量和严重程度。 患者需要一定的临床稳定性，因为单程旅行平均持续21小时 在火车上，先进的诊断或治疗选择是有限的。最初，的能力 推荐机构并不知道这列火车。因此，……的数量和/或敏锐度 这些患者往往比预期的要高。因为火车的医务人员负责 病人的健康状况，一旦他们上船，紧急的医疗和道德决定是否去做 接受病人的运输通常必须在平台上进行。接受意味着暴露 患者乘坐空间、ICU容量和救生限制的长途火车 手术，而拒绝则意味着把病人送回转诊医院 不为人所知。转诊指南的执行情况，并已分发给了卫生部 乌克兰的卫生部门、区域卫生部门和转诊医院(e附录1和 附录1中的附录2)大大改进了这一过程。一般来说，是基本的医疗培训 接受了所有年龄段、病情稳定且不需要ICU的患者。患者接受 如果其基线使用量小于5 L/min，则允许使用氧气。随着先进的部署 培训后，更多的危重患者可以被接受，并将标准扩展到患者接受 血管升压药或机械通气。 最初，乌克兰卫生部协助确定病人的运输和运输情况 与卫生、医院和不同的转诊和接受部门进行联络 机构他们收集了有关潜在候选人的信息，安排了往返于美国的交通工具 火车站，并帮助组织适当的分配病人到不同的接收 卫生机构随后，无国界医生组织设立了当地无国界医生组织的医疗联络职位 在东部城市德尼普罗的疏散火车上有经验的医生。联络人 与卫生部代表密切合作，建立了患者名单，并进行了核实 每一个病人转诊的适用性，检查火车上床位的可用性，以及 改善沟通。3个月后，医疗联络建立并处理 直接与各区域卫生部门进行转诊和接受病人。 JAMA网络打开。2023;6(6) :e2319726.doi： 10.1001/jamanetworkopen.2023.19726（转载）2023年6月23日3/9  **开放|乌克兰火车医疗疏散的全球健康特征，2022年**  一旦确定了最需要的保健设施，就计划了火车路线。 与铁路公司一起，寻求最近的无障碍火车站，安全 进行情况评估，并制定时间表。最初，火车路线只在出发前1到2天设定好， 允许最大限度的适应性，以应对最紧迫的人道主义需求。然而 这个系统对铁路公司来说是为了适应一个繁忙的铁路网 转诊医院及时确定并准备病人的转移。渐渐地，规划 火车路线演成为一个混合系统，还包括预先计划和重复的访问 某些地区。这有助于大型转诊医院提前制定计划，并允许对这些医院进行疏散 如孤儿院和精神病院等机构。确定的医疗联络人 需要紧急疏散的机构和能够接受具体类型的机构 病人被疏散。 **推荐的组织** 火车大部分时间在下午离开了基地城市利沃夫，并计划在第二天左右到达 中午需要仔细计划病人在平台上的时间 因存在安全风险而受到限制。为了说明为什么，不到一天后，基本的火车疏散了40人 来自克拉马托尔斯克的病人，多枚火箭击中了同一平台，造成至少50人死亡。11 在外出途中，工作人员为病人的到来准备了火车。医生 评估计划患者的名单，并预期需要分配的护理的严重程度和类型 适当的床位和资源。在火车到达前不久，病人被从 到火车站的卫生设施。理想情况下，救护车在到达后就在站台上排队。 然而，安全状况和救护车的有限供应导致了以下情况 在火车到达之前，救护车被延误或不得不离开去执行新的任务。这导致了 在平台上帮助调动的人员人数存在重大差异 病人上火车，有时迫使火车工作人员快速换班 策略是允许及时出发。第一次上船的经历导致了一次 标准化登船策略，旨在最大限度地减少时间损失分配每个病人 最佳的床位，同时仍然能够适应意外的情况(e附录3和 e附录1中的附录4）。一名医生协调登船，并对每个病人进行分诊 在进入火车之前，一名护士把他们分配到车厢内合适的床上。一个颜色 在分诊时，每个病人都有编码标签，以标记他们指定的车厢 入口处有颜色的国旗。最危重的病人都躺在附近的病床上 在基础列车上的护理站，或在高级列车上的ICU车厢内。患者是 较少需要护理的门诊被放置在普通卧铺车厢。不可移动的 病人由救护车人员或无国界医生组织的工作人员用担架抬进医院。作为 空间被限制在一个马车和限制在1个进入，担架需要携带在一个接一个或 在一系列中，施加压力的时间管理。先进的火车更宽敞 但总体上携带的非门诊患者较少。此外，它的长度为8节车厢意味着 车厢相距较远，可能会使一些较短的平台复杂化。 一上了火车，就会对每个病人进行彻底的评估，并进行必要的医疗检查 继续治疗，使安全和舒适的运输。在这些工作人员中，我们需要所有的工作人员 在工作人员转向轮班系统之前，最初的繁忙时间来解决病人并建立护理计划 在晚上有时也会使用与长期运输环境相关的特殊治疗方法， 比如周围神经阻滞。这些都是为了避免呼吸道并发症的选择 阿片类药物需求高的患者，由于伤口颠簸，移动，疼痛加重 火车诊断和治疗的选择仍然有限，而且非常罕见 如果病人的病情恶化，就会导致在火车站意外停车 在为紧急病人转到最近的适当的卫生保健机构的途中。实施 先进的医疗培训确保了更好的护理病情恶化的病人 允许运送更多的危重病人，推广其作为主要的火车使用 撤空  JAMA网络打开。2023;6(6) :e2319726.doi： 10.1001/jamanetworkopen（转载）2023年6月23日4/9.2023.19726  **开放|乌克兰火车医疗疏散的全球健康特征，2022年**  火车上的病人护理也不同于其他医院的常规院前运输护理 方面许多病人长期以来都被拒绝获得保健服务 随着医疗和社会病例的增加，工作人员经常从事初级保健，例如 重新开始对慢性医学共病的治疗。心理健康是许多人关心的一个主要问题 病人和必要的培训工作人员，关于如何帮助这些病人和如何应对 他们自己听到的故事。工作人员积极地确定了具体的社会或心理健康需求 患者，然后在到达后由无国界医生组织的社会工作者进行随访。他们主要提供 在庇护所各方面的援助、与家庭、慈善和志愿组织的联系、社会支持、 或者心理健康服务。 在准备第二天早上到达时，有明确的数量、严重程度、类型和流动性 患者需要被告知卫生部或区域卫生部门 允许规划到接收医院的运输计划。这些机构都是在相对较安全的地方 该国西部地区的医疗保健系统中断较少。然而，持续的 新撤离的病人的涌入可能很快就会淹没他们的能力。12创伤患者 需要进一步的手术或长期的康复往往可以转移到国外的医院 由欧盟公民保护机制推动。13相比之下，患者患有其他症状 医疗和社会护理需求仍然主要集中在乌克兰，并被有意识地分散出去 在几个西部省份重新分配病人的负荷。 下船后，一个无国界医生组织的后勤小组赶来清除垃圾，更换脏垃圾 亚麻布，并补充医疗材料和药品。后者被保存在标准化的盒子里 每次旅行后全部更换，不要浪费时间补充库存。一个清洁小组进行了清洁和消毒 马车和设备。几个小时后，火车经常再次离开。  **方法** 所有患者都收集了人口统计学和临床病例管理数据，作为常规检查的一部分 操作这些常规规划数据在前8个月进行了匿名化和分析 列车部署情况（2022年3月30日至11月30日）。患者的特征和临床特征 使用连续变量的中位数和范围和百分比进行分类 可变因素在适用的情况下，本报告遵循加强观察性报告之后 a287例患者的缺失数据。 b642例患者的缺失数据。 缩写： ICU，重症监护病房。 a医疗状况：急性疾病；不属于外科手术组、创 伤组或产科组的一部分。 b 非急性情况：需要疏散的弱势群体，但由于潜在情 况或极端年龄，没有能力乘坐定期客运列车。 c 创伤、意外事故：烧伤、跌倒、交通事故或其 他事故。 d 创伤，暴力：炸弹爆炸、枪弹、边缘武器、地雷、弹 片、弹丸、炮击或其他暴力。 表1。关于列车疏散和病人人口统计学特征的一般信息 变量 基本医疗列车 先进的医疗列车 两列列车 不疏散（%） 13 (18) 61 (82) 74 (100) 不患者（%） 483 (19) 1998 (81) 2481 (100) 男女比例a 0.88 1.12 1.07 中位年龄，y（范围）b 63 (1-94) 63 (0-98) 63 (0-98) 表2。推荐的原因 变量 不(%) 非ICU车厢患者 ICU车厢患者 所有患者 医疗状况a 548 (24) 57 (30) 605 (24) 非急性疾病b 1098 (48) 0 (0) 1098 (44) 产科 1 (<1) 1 (1) 2 (<1) 手术、非创伤（%） 52 (2) 3 (2) 55 (2) 创伤 意外的c 65 (3) 13 (7) 78 (3) 暴力的d 513 (22) 115 (61) 628 (25) 未分类的 15 (1) 0 15 (1) 合计 2292 (100) 189 (100) 2481 (100) JAMA网络打开。2023;6(6) :e2319726.doi： 10.1001/jamanetworkopen.2023.19726（转载）2023年6月23日  **开放|乌克兰火车医疗疏散的全球健康特征，2022年**  流行病学研究（频谱仪）观察性研究报告指南。这份手稿 符合无国界医生组织伦理审查委员会制定的后验分析的豁免标准 常规收集的临床数据，因此不需要由MSF伦理审查委员会的审查。它 是在得到布鲁塞尔无国界医生组织行动中心医务主任的许可下进行的。  **结果** 在8个月的时间里，他们进行了74次旅行，从11个城市疏散了2481名患者 前线。转运患者的中位年龄为63岁（范围，0-98岁），男性略多于男性 患者撤离（男女比例1.07，男性1136,46%，女性1058,43%；失踪 数据，287 [12%])。共有1098例患者（44%）来自非急性型的脆弱人群 作为转诊的医疗原因，721名患者（29%）最近或半近期有创伤， 605例患者（24%）有医疗疾病，55例患者（2%）有非创伤性手术疾病， 其中2例患者（<0.1%）患有产科疾病。关于列车疏散和 患者的人口统计学特征见表1，表2列出了各种原因 推荐。图中显示了患者转诊原因类型的演变。无患者 在火车上死亡，2421人（98%）到达了最终目的地，5名患者（0.2%）离开了火车 他们自己的自愿性；55名患者（2%）的数据缺失。7名患者被从 由于病情恶化，火车提前到达目的地；然而，这并没有在 常规数据收集。  数据显示所有(A)患者和重症监护病房（ICU）携 带(B).患者的数据 图长期以来通过医疗培训转诊的原因     JAMA网络打开。2023;6(6) :e2319726.doi： 10.1001/jamanetworkopen（转载）2023年6月23日6/9.2023.19726  **开放|乌克兰火车医疗疏散的全球健康特征，2022年**  在ICU车厢内运输的主要原因（n = 189）是急性呼吸衰竭 （16%）、血流动力学不稳定或休克（13%）、精神状态改变（21%）和代谢变化 干扰（5%）。其余部分为密切观察和监测（45%）。主 在ICU列车车厢内报告的干预措施为给氧（n = 41），侵入性 机械通气（n = 23），气管切开术护理（n = 18），中央线管理（n = 33）， 血管升压药（n = 5）和周围神经阻滞（n = 2）。 **讨论** 在冲突开始时，直接创伤病例构成了大多数撤离的病人，但他们的比例随着时间的推移而减少。在 ICU的火车车厢中，随着时间的推移，创伤仍然是转诊的主要原因，尽管也出现了类似的下降。这 在一定程度上可以归因于前线的稳定，减少了直接的平民伤亡。1,14此外，其他州和非州的行动者 开始为创伤患者提供长途运输，受冲突影响地区的医院增加了他们照顾ICU患者的能力。向患有慢 性共病的弱势人群、老年人和住院患者的转变，可以部分解释为卫生保健设施和服务的损害，破坏 了护理的连续性。5,6然而，创伤患者数量的减少也导致了更主动地识别这些弱势群体。 在整个战争期间，转诊医院似乎仍然有能力进行创伤的初级手术，并按照指南的指示，大多 稳定患者进行不太紧急的二级或三级手术，或康复。这反映为ICU列车车厢进入的主要原因是密切 观察和监测（45%）和最不需要血管升压剂治疗（3%）。然而，这些患者中有许多人仍病情危重， 因为有41例患者（22%）需要氧气，23例患者（12%）正在接受机械通气。 **限制** 我们报告的患者数据有其固有的局限性，这些数据主要是用于操作目的而收集的。这些数据包括 临床护理中缺失或不正确的数据和可变性，所有这些都限制了结果的有效性。 **结论** 本方案报告和病例系列描述了如何通过医疗化列车进行疏散，从而在饱受战争蹂躏的乌克兰改善获 得医疗保健的机会。通过调整现有车厢进行乘客运输，实现了列车快速调试的实现。然而，为了增 加所提供的护理水平 对ICU容量，并进行了广泛的结构重建。转诊指南、医疗联络和灵活的登船策略都有助于正确地选 择患者和改善船上患者的安全。此外，创伤病例在一开始构成了大多数运输；然而，随着时间的推 移，病人护理连续性的中断导致向更多的医疗和非急性转诊原因转变，并增加了对初级保健、心理 和保健的需要 社会关怀 **文章信息** **接受日期：2023年4月23日。** **出版：2023年6月23日。**doi :10.1001/jamanetworkopen.2023.19726 开放访问：这是一个在CC-BY许可条款下发布的开放获取文章。© 2023 Walravens S 以及其他人JAMA网络打开。 JAMA网络打开。2023;6(6) :e2319726.doi： 10.1001/jamanetworkopen.2023.19726（转载）2023年6月23日7/9  **开放|乌克兰火车医疗疏散的全球健康特征，2022年**  **通讯作者：** **James** **S。**李，医学博士，理学硕士， 内科，无国界医生-操作 比利时布鲁塞尔市中心，布塞尔街，布鲁塞尔1050号（james.lee@brussels.msf.org）。 作者附属机构：无国界医生部-布鲁塞尔行动中心， 比利时（瓦拉文斯，德韦格莱尔，李） ；根特大学医院急诊内科， 比利时根特（瓦拉文斯） ；运营部门，MedecinsSansFrontieres –OperationalCentreBrussels，Lviv， 乌克兰（扎尔科娃） ；无国界医生组织行动部-布鲁塞尔，布鲁塞尔， 比利时（伯顿，卡布罗尔） ；阿尔伯塔大学重症监护医学系，埃德蒙顿，阿尔伯塔省， 加拿大（李）。 作者贡献：沃拉文斯博士和李博士可以完全访问研究中的所有数据，并负责 数据的完整性和数据分析的准确性。 概念和设计：沃拉文斯，德韦格莱尔，伯顿，卡布罗尔，李。 数据的获取、分析或解释：瓦拉文斯、扎尔科娃、德韦格莱尔、伯顿、李。 手稿的起草人：瓦拉文斯、扎尔科娃、伯顿、卡布罗尔、李。 对重要知识内容的批判性修改：所有作者。 统计分析：瓦拉文斯、扎尔科娃、伯顿、李。 行政、技术或物质支持：瓦拉文斯、扎尔科娃、李。 监督：德韦格莱尔，李。 **利益冲突披露：没有报告。** 数据共享声明：见补充文件2。 **其他贡献：我们感谢乌克兰国家铁路无国界医生组织的所有现场工作人员** 乌克兰卫生保健公司，乌克兰卫生部，区域卫生部门，区域卫生保健部门 设施和救护车服务，使这个项目成为可能。我们感谢克里斯托弗 ·斯托克斯先生，理学硕士；夫人 卡特琳娜 ·塞尔比娜，BA；和梅丽莎夫人，BSN（无国界医生组织-布鲁塞尔行动中心） 对项目的持续支持。WethankMrsDoraNaliesna (allwithMedecinssansFrontieres-OperationalCentre 和理查德帕尔默先生（理查德帕尔默图形）为先进的医疗列车的插图。我们 感谢无国界医生中心-布鲁塞尔运营中心的所有部门和我们所有的顾问 沟通与他们的指导和支持。 **参考文献** **1.**联合国人权事务高级专员办事处。乌克兰：2月27日平民伤亡情况更新 2023.2023年2月27日。2023年4月13日通过。https://www.ohchr.org/en/news/2023/02/ukraine- civiliancasualty-update-27-february-2023 **2.**世界卫生组织。乌克兰的紧急情况：外部局势报告#19。2022年8月11日。2023年1月5日通过。 <https://www.who.int/publications/i/item/WHO-EURO-2022-5152-44915-65715> **3.**世界卫生组织。对医疗保健的攻击的监控系统。2022年12月31日。2022年12月31日通过。 a<https://extranet.who.int/ssa/LeftMenu/Index.aspx> **4.**洛哥斯汀，鲁宾斯坦。在乌克兰战争中对医疗保健的攻击： 国际法和问责制的必要性。JAMA。 2022;327(16) :1541-1542.doi :10.1001/jama.2022.6045 **5.**霉菌B，Ussai S，Pavlovych M，等。老年人：在乌克兰的人道主义灾难中，被遗忘的受害者。柳叶刀公 共卫生。2022;7(5) :e402-e403.doi :10.1016/S2468-2667(22)00087-1 **6.**梅西E，史密斯J，罗伯茨B。受中低收入国家人道主义危机影响的老年人口的保健需求：系统审查。确认健 康。2017;11(29) :29.doi :10.1186/s13031-017-0133-x **7.**莱瑟曼S，塔菲克L。在冲突环境中提高护理质量：获得医疗服务和基础设施是最基本的。国际医疗保健 公司。2019;31(10) :G187-G190.doi :10.1093/intqhc/mzz128 **8.**马布里，马布里，马布里，等。衡量美国陆军医疗后送：绩效改进的指标。j创伤急性护理冲浪。 2018;84(1) :150-156.doi :10.1097/TA.0000000000001715 **9.**凯利A。救护车列车。地中海医学研究所2001;76(2) :153.doi :10.1097/00001888-200102000-00012 **10.**兰豪特，尼维特，达格伦， 内斯，布劳恩，卡利P。关于法国新冠肺炎危机期间高速列车医疗转移的反馈：查登 使团。Ann Fr Med洗脱。2020;10(4-5) :288-297.doi :10.3166/afmu- 2020-0275 **11.**谢尔顿M。俄罗斯克拉马托尔斯克的“事实 ”与证据的对比。贝灵猫。2022年4月14日。1月5日访问， 2023. https://www.bellingcat.com/news/2022/04/14/russias-kramatorsk-facts-versus-the-evidence JAMA网络打开。2023;6(6) :e2319726.doi： 10.1001/jamanetworkopen（转载）2023年6月23日8/9.2023.19726  **开放|乌克兰火车医疗疏散的全球健康特征，2022年**  **12.**坎迪A。“他本应该活下去 ”：事实证明，利沃夫的医院的短缺是致命的。卫报2022年4月26日。2023年1月5 日通过。https://www.theguardian.com/global-development/2022/apr/26/shortages-provingfatal-in-lviv -hospitals **13.**欧盟已准备好欢迎那些逃离乌克兰战争的人。欧委会2022年3月23日。2023年1月5日通过。 https://ec.europa.eu/migrant-integration/news/ec-communication-welcoming-thosefleeing-war-ukraine- readying-europe-meet-needs\_en **14.**巴罗斯G，斯特帕年科K，贝杰隆T。互动地图：俄罗斯入侵乌克兰。战争研究研究所和美国企业研究所的关键威 胁项目。2022年5月23日。2023年1月5日通过。https:// arcg.is/09O0OS **补充1。** eFigure.先进医疗列车车厢设置详图 **eAppendix** **1.**信息手册基本医疗疏散培训-2022年4月版 **eAppendix** **2.**信息传单先进的医疗疏散培训MSF-版本2022年5月 **eAppendix** **3.**基本医疗疏散列车的出发-2022年4月版 **eAppendix** **4.**先进医疗疏散列车MSF-2022年5月版 **补充2。** **数据共享声明** JAMA网络打开。2023;6(6) :e2319726.doi： 10.1001/jamanetworkopen（转载）2023年6月23日9/9日.2023.19726  JAMA Network  en TM  **Original Investigation | Global Health** Characteristics of Medical Evacuation by Train in Ukraine, 2022 Stig Walravens, MD; AlbinaZharkova, MD, PhD; Anja DeWeggheleire, MD, MPH; Marie Burton, MPH; Jean-Clément Cabrol, MD; James S. Lee, MD, MSc **Abstract** **IMPORTANCE** The 2022 war in Ukraine severely affected access to health care for patients in the conflict-affected regions and limited options for medical evacuation. Air transport, a common method of medical evacuation in war zones, was unsafe due to the conflict of 2 modernized military forces that were in possession of aircraft and surface-to-air weapons; therefore, Médecins Sans Frontières, in collaboration with the Ukrainian railway company and Ukrainian health agencies, addressed this by initiating medical evacuation via medically customized trains. **OBJECTIVE** To describe the implementation of medical evacuation trains aimed at improving the access to health care for war-affected patients. **DESIGN, SETTING, AND PARTICIPANTS** This case series describes the remodeling of 2 trains used for medical evacuation in a conflict zone during the war in Ukraine. The study was conducted from March 30 to November 30, 2022. One train had minimal adjustments and could be rapidly deployed to address the most pressing humanitarian needs, while the other underwent major structural modifications to provide intensive care capacity. The report details the medical capabilities of the trains, the organization of referrals, and operational challenges encountered. Additionally, it includes a case series on the characteristics of patients transported in the initial 8 months,based on routinely collected programmatic descriptive data of all patients transported by the medical trains. **RESULTS** In 8 months, 2481 patients (male-female ratio, 1.07; male, 1136 [46%]; female 1058 [43%]; missing data, 287 [12%]; median age, 63 years [range, 0-98 years]) were evacuated from 11 cities near the Ukrainian conflict frontline to safer areas. Initially, the trains predominantly evacuated trauma patients,but over the course of the war, the patient characteristics changed with more medical and nonacute conditions, and fewer trauma patients. The main reason for entry into the intensive care unit train carriage was for close monitoring and observation, and the main interventions performed were primarily for respiratory failure. **CONCLUSIONS AND RELEVANCE** The findings of this study suggest that medical evacuation in a war zone by converted trains is possible and can improve access to health care for war-affected patients. The presence of intensive care capacity on board allows for transport of more severely ill or injured individuals. However, the target population should not be limited to trauma patients, as health care institutions affected host a much broader population whose needs and urgency for evacuation may change over time. JAMA Network Open. 2023;6(6):e2319726. doi[:10.1001/jamanetworkopen.2023.19726](https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2023.19726&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2023.19726)  **Open Access.** This is an open access article distributed under the terms of the CC-BY License. **Key Points** **Question** How can medical evacuation trains be implemented in a war zone and what type of patients can be expected? **Findings** This case series describes medical evacuation by train during the 2022 Ukraine conflict using 2 trains. Over 8 months, the medical trains made 74 journeys, evacuating 2481 patients from 11 cities close to the frontline; during this period, the most common type of patients transported changed from trauma-related casualties to patients with medical and nonacute reasons for referral. **Meaning** The findings of this study suggest that medical evacuation by train can be feasible in a conflict zone with a preexisting railway network, if adapted to local conditions and an evolving patient population. **+** [**Invited Commentary**](https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2023.19687&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2023.19726) **+** [**Supplemental content**](https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2023.19726&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2023.19726) Author affiliations and article information are listed at the end of this article. JAMA Network Open. 2023;6(6):e2319726. doi:10.1001/jamanetworkopen.2023.19726 June 23, 2023 1/9 **Downloaded from jamanetwork.com by guest on 11/30/2023** **JAMA Network Open | Global Health** Characteristics of Medical Evacuation by Train in Ukraine, 2022 **Introduction** At the first anniversary of the 2022 war in Ukraine, a report of the office of the High Commissioner for Human Rights reported 21580 civilian casualties of whom 8101 were killed, noting the actual figures could be considerably higher due to minimal information from areas most under siege.1 Access to safe and essential medical care near the frontline was severely compromised due to active weaponized combat and limited transportation options due to roadblocks, damaged roads, and collapsed bridges. Health care staff fled, hundreds of health care facilities were attacked, and the remaining functional medical services were overwhelmed with trauma patients.2-4 Moreover, the initial mass evacuations of affected areas often left older, sick, or institutionalized people behind without continuity of care, which sooner or later put them in a situation that required medical evacuation.5-7 Médecins Sans Frontières (MSF), an independent, medical humanitarian organization already present in Ukraine before the war, explored ways to relieve overcrowded hospitals and bring conflict- affected patients to safer regions. Air transport, the most frequently reported technique of medical evacuation in war zones,8 was unsafe due to the conflict of 2 modernized military forces possessing aircraft and surface-to-air weapons. Furthermore, the airspace was closed to civilian aircraft. Evacuation by road had inherent challenges due to long distances, frequent roadblocks, and greater need for human and material resources. However, Ukraine’s railway system was initially only minimally affected, allowing for the transportation of larger numbers of patients to safe areas. Minimal literature exists on this alternative evacuation modality. The last large-scale wartime medical evacuation by train took place during the Korean conflict of 1950 to 1953.9 However, more recently, train transport of patients with COVID-19 to intensive care units (ICUs) happened in France.10 This study describes a program of medical evacuation by train aimed at improving access to health care for war-affected patients. It reports on the remodeling of 2 trains for medical use, including 1 with ICU capacity, staffing, patientselection, train routeselection, organization of referrals, and associated operational challenges. Additionally, it includes a case series on the characteristics of patients transported in the initial 8 months, need for referral, and the type of care provided. **Program Description** **Train Adaptations** The medical and logistic department of the MSF drafted feasibility, technical, and strategic plans, and consulted local stakeholders. In collaboration with the National Ukrainian railway company, 2 Ukrainian-made passenger trains were adapted to prepare them for medical transport. Remodeling was guided by previous experience with COVID-19 trains in France.10 However, aspects of war and the local context needed to betaken into consideration. The basic medical train had minimal modifications and was launched to respond quickly to the most pressing humanitarian needs. It consisted of 2 sleeper carriages with modified partitions to allow stretchers to enter, 1 sleeper carriage for ambulatory patients with less severe conditions, and 1 staff carriage. Patients’ companions could stay in the upper bunk beds or in unoccupied lower beds. The train was equipped with medications and materials, oxygen concentrators, suctioning, and emergency equipment for intubation or chest drains. Up to 32 immobile patients and 27 ambulatory patients could be transferred. While the basic train was put in use on March 31, 2022, construction of a more advanced medical train with ICU capacity was still under way (eFigure in[Supplement 1](https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2023.19726&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2023.19726)). Extensive remodeling was performed, modifying the electrical system and stripping the interior to accommodate hospital beds and equipment. The train consisted of 8 carriages: 1 carriage with 5 ICU beds of which 2 could offer invasive mechanical ventilation, 2 carriages with 9 beds for nonambulatory patients, 1 regular sleeper carriage, and 1 carriage with beds and mattresses for ambulatory patients with nonsevere conditions and their companions. The 3 remaining carriages were for staff, medical stock, oxygen  JAMA Network Open. 2023;6(6):e2319726. doi:10.1001/jamanetworkopen.2023.19726 June 23, 2023 2/9 **Downloaded from jamanetwork.com by guest on 11/30/2023** **JAMA Network Open | Global Health** Characteristics of Medical Evacuation by Train in Ukraine, 2022 generators, and an uninterruptable power supply, which was needed to allow transport of ICU patients over long distances on an unreliable electrical railway grid. Exclusive use of oxygen cylinders was deliberately not considered as the train risked being stuck for long periods in case of damaged railway infrastructure and would carry a high explosive risk in a war zone. The oxygen-generating system could provide oxygen at a rate of 30 L/minto each ICU bed, while the 2 ICU beds with mechanical ventilation were able to provide 60 L/min and constant pressure between 2.8 and 6.0 bars needed for the ventilator. The structural changes, technical modifications, and equipment installations of the advanced medical train took 23 days, and first deployment happened on April 24, 2022. Minor adjustments continued after train deployment. Air conditioning was installed in the spring, while the oxygen carriage was equipped with electrical heating and thermally insulated oxygen pipes for winter temperatures to preserve the functioning of oxygen generators, which highlights the importance of being able to further modify the trains after deployment to react to encountered or anticipated problems. **Train Staff** Apart from a few MSF international staff, it was mainly local individuals who were recruited to staff the train. These were physicians with ICU experience, nurses, nurse aides, technical logisticians, and a translator. The number of staff increased over time, allowing more rotations and more nurses per patient. International staff consisted of a project coordinator, an emergency/ICU physician, a nurse manager, and once the advanced train was launched, an ICU nurse. Local staff were trained to gradually take over some of these positions. Ukrainian Railway staff remained in charge of routine train functioning and movements. **Patient and Train RouteSelection** The number and severity of patients referred needed to be considered when accepting a transfer. Patients required a certain clinical stability for transport as a 1-way trip lasted, on average, 21 hours and advanced diagnostic or therapeutic options on the train were limited. Initially, the capacities of the train were not well known to the referring institutions. As a result, the number and/or acuity of the patients was often higher than anticipated. Because the train’s medical staff was responsible for the health of patients once they were on board, urgent medical and ethical decisions whether to accept patients for transport often had to be made on the platform. Acceptance meant exposing the patient to a long train journey with constraints in space, ICU capacity, and access to life-saving surgery, while refusal meant sending the patient back to the referring hospital where conditions were not well known. The implementation of referral guidelines, which were distributed to the Ministry of Health of Ukraine, regional departments of health and referring hospitals (eAppendix 1 and eAppendix 2 in[Supplement 1](https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2023.19726&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2023.19726)) improved this process considerably. In general, the basic medical train accepted patients of all ages in stable condition and without ICU requirement. Patients receiving oxygen were allowed if their baseline usage was less than 5 L/min. With deployment of the advanced train, more critically ill patients could be accepted, and criteria were extended to patients receiving vasopressors or mechanical ventilation. Initially, the Ministry of Health of Ukraine assisted in identifying patients for transport and functioned as liaison with the different referring and accepting departments of health, hospitals, and institutions. They collected information on potential candidates, arranged transport to and from the railway stations, and helped organize appropriate distribution of patients to different receiving health care facilities. Subsequently, MSF established the position of medical liaison, a local MSF physician with experience on the evacuation train, based in the eastern city of Dnipro. The liaison collaborated closely with the Ministry of Health representative in establishing patient lists, verifying the suitability of every proposed patient transfer, checking bed availability on the train, and improving communications. After 3 months, the medical liaison was well established and dealt directly with the various regional departments of health for both referral and acceptance of patients.  JAMA Network Open. 2023;6(6):e2319726. doi:10.1001/jamanetworkopen.2023.19726 June 23, 2023 3/9 **Downloaded from jamanetwork.com by guest on 11/30/2023** **JAMA Network Open | Global Health** Characteristics of Medical Evacuation by Train in Ukraine, 2022 Once health care facilities most in need were identified, a train route itinerary was planned. Together with the railway company, the closest accessible railway station was sought, security situation assessed, and timetable set. Initially, train routes were set only 1 or 2 days before departure, allowing maximum adaptability to respond to the most pressing humanitarian needs. Nevertheless, this system was strenuous for the railway company to fit it into a busy railway network and for referring hospitals to identify and prepare their patients for transfer on time. Gradually, the planning of train routes evolved into a mixed system that also included preplanned and repetitive visits to certain regions. This helped large referral hospitals to plan ahead and allowed for the evacuation of institutions such as an orphanage and psychiatric institutions. The medical liaison identified institutions requiring urgent evacuation and institutions that could accept the specific type of patients being evacuated. **Organization of the Referral** The train mostly left the base city of Lviv in the afternoon and planned to arrive the next day around midday. Embarkment of patients needed to be carefully planned as time on the platform was restricted due to safety risks. To illustrate why, less than a day after the basic train evacuated 40 patients from Kramatorsk, multiple rockets hit the same platform, killing at least 50 individuals.11 During the outward journey, staff prepared the train for the arrival of patients. Physicians assessed the list of planned patients and anticipated the severity and type of care needed to allocate beds and resources properly. Shortly before arrival of the train, patients were transferred from the health facilities to the railway station. Ideally, ambulances queued up at the platform on arrival. Nevertheless,the security situation and limited availability of ambulances led to situations in which ambulances were delayed or had to leave for a new assignment before the train arrived. This resulted in major differences in the number of personnel who were present on the platform to help transfer patients onto the train, and sometimes forced the train staff to make quick shifts in embarkment strategy in order to allow for a timely departure. The experience of the first embarkmentsled to a standardized embarkment strategy aimed at minimizing time loss in assigning each patient to the most optimal bed position while still being able to adapt to unexpected situations (eAppendix 3 and eAppendix 4 in[Supplement 1)](https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2023.19726&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2023.19726). A physician coordinated the embarkment and triaged every patient before entry in the train, while a nurse assigned them to a suitable bed within the carriages. A color- coded tag was pinned to each patient at triage to signal their assigned carriage, which had a corresponding-colored flag at the entrance. The most critical patients were positioned in beds near the nursing station in the basic train or in the ICU carriage in the advanced train. Patients who were ambulatory with less need of nursing care were placed in a regular sleeper carriage. Nonambulatory patients were carried in on a stretcher by ambulance personnel or by MSF staff in their absence. As space is restricted in a carriage and limited to 1 entry, stretchers needed to be carried in one-by-one or in series, pressuring time management. The advanced train was more spacious to maneuver inside but carried fewer nonambulatory patients overall. Furthermore, its length of 8 carriages meant carriages were further apart and could complicate accessibility from some shorter platforms. Once on the train, a thorough assessment of each patient took place, and the necessary medical treatment was continued to allow safe and comfortable transport. All staff were needed in these initial busy hours to settle patients and establish a care plan before staff could switch to a shift system in the evening. Specialized treatments relevant for a long transport context were sometimes used, such as peripheral nerve blocks. These were performed to avoid respiratory complications in selected patients with high opioid requirements due to aggravated pain of their injuries by a bumpy, moving train. Diagnostic and therapeutic options remained limited on the basic medical train and, on rare occasions if patients’ conditions deteriorated, this resulted in an unplanned stop at a railway station en route for an urgent patient transfer to the closest appropriate health care facility. Implementation of the advanced medical train ensured better care of the patients with deteriorating status and allowed for the transport of more critically ill patients, promoting it as the main train used for evacuations.  JAMA Network Open. 2023;6(6):e2319726. doi:10.1001/jamanetworkopen.2023.19726 June 23, 2023 4/9 **Downloaded from jamanetwork.com by guest on 11/30/2023** **JAMA Network Open | Global Health** Characteristics of Medical Evacuation by Train in Ukraine, 2022 Patient care onboard the trains also differed from regular prehospital transport care in other aspects. Many patients had been denied access to health services for a long time, and with the increase in medical and social cases, the staff was frequently engaged in primary health care, such as restarting treatment for chronicmedical comorbidities. Mental health was a major concern for many patients and necessitated training staff on how to assist these patients and how to cope with the stories they heard themselves. Staff actively identified specific social or mental health needs in patients, which were then followed up by MSF social workers after arrival. They mostly provided assistance on aspects of shelter, links to family, charity and volunteer organizations, social support, or mental health services. In preparation of arrival the next morning, the definite number, severity, type, and mobility of patients needed to be communicated to the Ministry of Health or regional departments of health to allow planning of transport to the receiving hospitals. These institutions in the relatively safer western regions of the country had less disrupted health care systems. Nevertheless, a sustained influx of newly evacuated patients could soon overwhelm their capacity.12 Trauma patients who needed further surgery or long-term rehabilitation could often be transferred to hospitals abroad facilitated by the European Union Civil Protection Mechanism.13 In contrast, patients with other medical and social care needs remained predominantly in Ukraine and were consciously dispersed across several western provinces to redistribute the patient load. After disembarkment, an MSF logistical team came on board to remove garbage, replace dirty linen, and restock medical material and drugs. The latter were kept in standardized boxes and replaced entirely after each trip, not to lose time restocking. A cleaning team cleaned and disinfected the carriage and equipment. A few hours later, the train often left again. **Methods** All patients had demographic and clinical case management data collected as part of routine operations. These routine programmatic data were anonymized and analyzed for the first 8 months of train deployment (March 30 to November 30, 2022). Patient characteristics and clinical features were summarized using medians and ranges for continuous variables and percentages for categorical variables. Where applicable, this report follows the Strengthening the Reporting of Observational a Missing data of 287 patients. b Missing data of 642 patients. Table 1. General Information on Train Evacuations and Patient Demographic Characteristics Variable Basic medical train Advanced medical train Both trains No. of evacuations (%) 13 (18) 61 (82) 74 (100) No. of patients (%) 483 (19) 1998 (81) 2481 (100) Male/female ratioa 0.88 1.12 1.07 Median age, y (range)b 63 (1-94) 63 (0-98) 63 (0-98) Abbreviation: ICU, intensive care unit. a Medical condition: acute illness; not part of the surgical, trauma, or obstetrics groups. b Nonacute condition: vulnerable population in need of evacuation, but without capabilities to take regular passenger train due to underlying condition or extremes of age. c Trauma, accidental: burns,falls, traffic, or other accidents. d Trauma, violent: bomb blast, gunshot, edge weapon, landmine, shrapnel, projectile, shelling, or other violence. Table 2. Reasons for Referral Variable No. (%) Patients of non-ICU carriages Patients of ICU carriage All patients Medical conditiona 548 (24) 57 (30) 605 (24) Nonacute conditionb 1098 (48) 0 (0) 1098 (44) Obstetrics 1 (<1) 1 (1) 2 (<1) Surgical, nontrauma (%) 52 (2) 3 (2) 55 (2) Trauma Accidentalc 65 (3) 13 (7) 78 (3) Violentd 513 (22) 115 (61) 628 (25) Unclassified 15 (1) 0 15 (1) Total 2292 (100) 189 (100) 2481 (100)  JAMA Network Open. 2023;6(6):e2319726. doi:10.1001/jamanetworkopen.2023.19726 June 23, 2023 5/9 **Downloaded from jamanetwork.com by guest on 11/30/2023** **JAMA Network Open | Global Health** Characteristics of Medical Evacuation by Train in Ukraine, 2022 Studies in Epidemiology ([STROBE](https://www.equator-network.org/reporting-guidelines/strobe/)) reporting guideline for observational studies. This manuscript fulfilled the exemption criteria set by the MSF Ethics Review Board for a posteriori analysis of routinely collected clinical data and thus did not require review by the MSF Ethics Review Board. It was conducted with permission of the medical director of MSF Operational Centre Brussels. **Results** In 8 months, the MSF trains made 74 journeys, evacuating 2481 patients from 11 cities close to the frontline. The median age of transported patients was 63 (range, 0-98) years, and slightly more male patients were evacuated (male-female ratio, 1.07; male, 1136 [46%]; female 1058 [43%]; missing data, 287 [12%]). Atotal of 1098 patients (44%) were from a vulnerable population with a nonacute condition as the medical reason for referral, 721 patients (29%) had a recent or semirecent trauma, 605 patients (24%) had a medical condition, 55 patients (2%) had a nontraumatic surgical condition, and 2 patients (<0.1%) had an obstetric condition. General information on train evacuations and patient demographic characteristics can be found in **Table 1**, and **Table 2** lists the various reasons for referral. The **Figure** shows the evolution of the type of reason for referral of the patients. No patient died on the train, 2421 (98%) reached the final destination, and 5 patients (0.2%) left the train on their own accord; data were missing for 55 patients (2%). Seven patients were transferred from the train before arrival at destination due to medical deterioration; however, this was not captured in the routine data collection. Figure. Reasons for Referral by Medical Train Over Time **A** 450 400 350 300 250 200 150 100 50 0 Transported patients, No. Transported patients, No. **B** All patients Including 87 babies patients from Including 269 psychiatric institution Including 208 patients from and toddlers evacuated psychiatric institution from orphanage  March 30 May June July August September October November to April 31 Month in 2022 Patients in ICU carriage 35 30 25 20 15 10 5 0 April 25 to May 31 June July August September October November Month in 2022 Referred pathology  Medical condition  Nonacute condition (high-risk population or humanitarian evacuations)  Surgical (nontrauma) condition Obstetrics  Trauma accidental (burns, falls, traffic, or other accidents)  Trauma violent (bomb blast, gunshot, edged weapon, landmine, shrapnel or projectile, shelling, or other violence)  Trauma unclassified Data shown for all patients (A) and patients in the intensive care unit (ICU) carriage (B).  JAMA Network Open. 2023;6(6):e2319726. doi:10.1001/jamanetworkopen.2023.19726 June 23, 2023 6/9 **Downloaded from jamanetwork.com by guest on 11/30/2023** **JAMA Network Open | Global Health** Characteristics of Medical Evacuation by Train in Ukraine, 2022 The main reasons for transport in the ICU carriage (n = 189) were for acute respiratory failure (16%), hemodynamic instability or shock (13%), altered mental status (21%),and metabolic disturbances (5%). The remainder was for close observation and monitoring (45%). The main interventions reported inside the ICU train carriage were oxygen administration (n = 41), invasive mechanical ventilation (n = 23),tracheostomy care (n = 18), central line management (n = 33), vasopressors (n = 5), and peripheral nerve blocks (n = 2). **Discussion** At the beginning of the conflict, direct trauma cases constituted most of the evacuated patients, but their proportion diminished over time. In the ICU train carriage, trauma continued to be the main reason for referral over time, although a similar decrease occurred. In part, this could be attributed to the stabilization of the frontline with fewer direct civilian casualties.1,14 Furthermore, other state and nonstate actors started to provide long-distance transport of trauma patients, and hospitals in conflict-affected regions increased their capacity to care for ICU patients. The shift toward vulnerable populations with chronic comorbidities, older individuals, and institutionalized patients could partly be explained by the impairment of health care facilities and services disrupting the continuity of care.5,6 However, the reduced number of trauma patients also led to more proactive identification of these vulnerable groups. Throughout the war, referring hospitals still seemed to be capable of performing primary surgery for trauma and referred, as the guidelines instructed, mostly stabilized patients for less- urgent secondary or tertiary surgery, or for rehabilitation. This is reflected as the main reason for ICU train carriage entry was for close observation and monitoring (45%) and in the minimal need of vasopressor (3%) treatment. Nevertheless, many of these patients were still critically ill, as 41 patients needed oxygen (22%) and 23 patients (12%) were receiving mechanical ventilation. **Limitations** There are inherent limitations to our reported patient data, which were collected primarily for operational purposes. These included missing or incorrect data and variability in clinical care, all of which limit the validity of the results. **Conclusions** This program report and case series describes how evacuation by means of medicalized trains improved access to health care in war-torn Ukraine. Rapid commissioning of a train was achieved by adapting existing carriages for patient transport. However, to increase thelevel of care providedwith ICU capacity, an extensive structural remodeling was performed. Referral guidelines, a medical liaison, and a flexible embarkment strategy all helped in correct patientselection and improved patient safety on board. In addition, trauma cases constituted most transports at the beginning; however, the disruption of patient care continuity caused a shift toward more medical and nonacute reasons for referral over time and increased the need for primary health, psychological, and social care. **ARTICLE INFORMATION** **Accepted for Publication:** April 23, 2023. **Published:** June 23, 2023. doi[:10.1001/jamanetworkopen.2023.19726](https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2023.19726&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2023.19726) **Open Access:** This is an open access article distributed under the terms of the[CC-BY License.](https://jamanetwork.com/pages/cc-by-license-permissions/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2023.19726) © 2023 Walravens S et al. JAMA Network Open.  JAMA Network Open. 2023;6(6):e2319726. doi:10.1001/jamanetworkopen.2023.19726 June 23, 2023 7/9 **Downloaded from jamanetwork.com by guest on 11/30/2023** **JAMA Network Open | Global Health** Characteristics of Medical Evacuation by Train in Ukraine, 2022 **Corresponding Author:** James S. Lee, MD, MSc, Medical Department, Médecins Sans Frontières–Operational Centre Brussels, Rue de l'Arbre Bénit 46, 1050 Brussels, Belgium [(james.lee@brussels.msf.org)](mailto:james.lee@brussels.msf.org). **Author Affiliations:** Medical Department, Médecins Sans Frontières–Operational Centre Brussels, Brussels, Belgium (Walravens, DeWeggheleire, Lee); Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium(Walravens);Operations Department, Médecins Sans Frontières–Operational Centre Brussels, Lviv, Ukraine (Zharkova); Operations Department, Médecins Sans Frontières–Operational Centre Brussels, Brussels, Belgium (Burton, Cabrol); Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada (Lee). **Author Contributions:** Drs Walravens and Lee had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Walravens, DeWeggheleire, Burton, Cabrol, Lee. Acquisition, analysis, or interpretation of data: Walravens, Zharkova, DeWeggheleire, Burton, Lee. Drafting of the manuscript: Walravens, Zharkova, Burton, Cabrol, Lee. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Walravens, Zharkova, Burton, Lee. Administrative, technical, or material support: Walravens, Zharkova, Lee. Supervision: DeWeggheleire, Lee. **Conflict of Interest Disclosures:** None reported. **Data Sharing Statement:** See[Supplement 2.](https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2023.19726&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2023.19726) **Additional Contributions:** We thank all field staff of Médecins Sans Frontières,the Ukrainian state railway company Ukrzaliznytsia, the Ukrainian Ministry of Health, regional departments of health, regional health care facilities, and ambulance services for making this project possible. We thank Mr Christopher Stokes, MSc; Mrs Kateryna Serbina, BA; and Mrs Melissa How, BSN (Médecins sans Frontières-Operational Centre Brussels),for their ongoing support to the project. We thank Mrs DoraNaliesna(allwith Médecins sans Frontières-Operational Centre Brussels) and Mr Richard Palmer (Richard Palmer Graphics) for the illustration of the advanced medical train. We thank all departments from Médecins Sans Frontières–Operational Centre Brussels and all advisors we have communicated with for their guidance and support. **REFERENCES** **1**. Office of the United Nations High Commissioner for Human Rights. Ukraine: civilian casualty update 27 February 2023. February 27, 2023. Accessed April 13, 2023.[https://www.ohchr.org/en/news/2023/02/ukraine-civilian-](https://www.ohchr.org/en/news/2023/02/ukraine-civilian-casualty-update-27-february-2023) [casualty-update-27-february-2023](https://www.ohchr.org/en/news/2023/02/ukraine-civilian-casualty-update-27-february-2023) **2**. World Health Organization. Emergency in Ukraine: external situation report #19. August 11, 2022. Accessed January 5, 2023.<https://www.who.int/publications/i/item/WHO-EURO-2022-5152-44915-65715> **3**. World Health Organization. Surveillance system for attacks on healthcare. December 31, 2022. Accessed December 31, 2022. 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Institute for the Study of War and the American Enterprise Institute’s Critical Threats Project. May 23, 2022. Accessed January 5, 2023.[https://](https://arcg.is/09O0OS) [arcg.is/09O0OS](https://arcg.is/09O0OS) **SUPPLEMENT 1.** **eFigure.** Detailed Diagram of the Set-up of the Carriages for the Advanced Medical Train **eAppendix 1.** Information Leaflet Basic Medical Evacuation Train MSF—Version April 2022 **eAppendix 2.** Information Leaflet Advanced Medical Evacuation Train MSF—Version May 2022 **eAppendix 3.** Embarkment of Basic Medical Evacuation Train MSF—Version April 2022 **eAppendix 4.** Embarkment of Advanced Medical Evacuation Train MSF—Version May 2022 **SUPPLEMENT 2.** **Data Sharing Statement**  JAMA Network Open. 2023;6(6):e2319726. doi:10.1001/jamanetworkopen.2023.19726 June 23, 2023 9/9 **Downloaded from jamanetwork.com by guest on 11/30/2023**
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2024年12月5日 17:26
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