Phased-in treatment

Step treatment is a system of treatment of the wounded and sick in wartime, the essence of which consists in serial and successive carrying out of remedial measures in health centers and hospitals (so-called stages of medical evacuation) in conjunction with the evacuation.
The founder of military field surgery N. I. Pirogov, created in the second half of the 19th century advanced doctrine about the organization of medical support of the army, was of great importance for the evacuation of the wounded and saw it as a medical function. According to the experience of their work in Sevastopol campaign of 1853-1856 he considered necessary the creation of a special medical-transport team consisting of physicians, feldshers, nurses. It was allocated staff to accompany the transport of the wounded. On the ground evacuation routes have been established canteens, rest and overnight evacuated, and on the main stages to be providing medical care and identification of the wounded, the condition of which has deteriorated, are not subject to health-evacuation and lehtoranta (ill)to be sent to weak team. Great value was given to Pirogov sorting of the wounded (see Sorting medical), he developed the principles and methods of its implementation. Advanced, rational doctrine N. I. Pirogov was not used in the practical activity of the medical service of the Russian army. The evacuation of the wounded and sick has been regarded as the most important indicator of the activity of the medical service in full isolation from the treatment. So it was in the Russo-Japanese and especially in the first world war.
This practice, causing great damage to the cause of treatment of the wounded and sick, caused protests from leading Russian scientists. In 1916-1917, C. A. Oppel proposed a system of staging treatment, which was intimately linked evacuation to medical treatment, to consider them summands of the whole. C. A. Oppel believed that the evacuation from the outset be handled so as to put on the first place the interests of the wounded from the point of view, he needs treatment. "Wounded receives such surgical allowance, when and where and when in this manual found the need. The wounded were evacuated at such a distance from the line of battle, what is most beneficial for his health." Although this wording, to a certain extent-can be traced to an underestimation of the impact of combat conditions for organization of medical-evacuation support for the troops, but in General the proposed Century A. Oppel system was rational and progressive. However, in pre-revolutionary Russia the system of staging treatment was not implemented.
Only after the great October socialist revolution the principles of staging treatment were the basis of medical-evacuation of the security of troops and was further creative development. The system first stage of treatment was based on the so-called drainage type evacuation, when the evacuation of the wounded and sick are coherent with advanced stage for the next, located in the rear of the stage. Such organization staging treatment was regulated by the "guidelines on sanitary evacuation in the red army" (1929). At that time the medical service had to evacuate on dirt paths only horse transport, and specialization of hospitals was still in its infancy. As equipping of medical services by motor and air transport and introduction of principles of specialized medical care continued to improve the system of staging treatment. The basis of medical-evacuation ensure that the army was based on the principle of staging treatment with evacuation on purpose. The development of this system was carried out between 1931 and 1940, but its final registration occurred already during the great Patriotic war. The availability of high-speed transports and a wide network of specialized hospitals were allowed instead of compulsory evacuation of the wounded and sick from stage to stage ("drainage" type) qualified to perform after sorting (at divisional health centres) evacuation on purpose to appropriate medical institution where the injured person (the patient) could be provided with the necessary skills and specialized medical aid, bypassing intermediate stages (see Medical care in the military field conditions). This order the evacuation contributed to reducing the number of stages through which passed the wounded and sick, and gave the opportunity rather to provide evacuated necessary specialized medical help. The system of staging treatment with evacuation by assignment, turned out quite appropriate in the years of the great Patriotic war, remains one of the most important principles of medical-evacuation support.
In terms of staging treatment, in contrast to the treatment in time of peace, the healing process is not in one medical institution, and is scattered between different stages of medical evacuation, often remote from each other, and held various groups of health workers. This raises an important requirement for therapeutic intervention in the system of staging treatment - continuity of treatment. Continuity is achieved by the unity of the principles of medical-evacuation actions and the presence of a brief but concise documentation (see Documentation medical), compiled on each evacuated and accompanying him to the point where he finished his treatment.
Shortly before the great Patriotic war have been developed (under the guidance of E. I. Smirnova N. N. Burdenko) single installation on conducting staging treatment. These units provided a common understanding of the development of pathological processes in the war, unity of views on the methods of treatment, a common understanding of the principles of surgical and therapeutic activities and the organization of stages of medical evacuation. The main provisions of these facilities is presented in different guidance documents and papers on the most important military medicine. For example, in the field military surgery these settings are regulated by the following provisions: all gunshot wounds are initially infected (bacterial contamination); the only reliable method of preventing infection is early surgical treatment which is needed by the majority of the wounded. Here was done organizational conclusions about the rapid removal of the wounded from the battlefield and delivering them to the stages of medical evacuation, where they could be rendered first medical qualified assistance; specialized medical care should begin with military field hospitals.
The presence of common installations played an extremely important role in the success of the medical service in the Great Patriotic war. Of great importance to ensure continuity of medical care in the system of staging treatment had and medical documentation (primary health card, the case history on each wounded and sick etc), which brought information about the diagnosis and the assistance provided at the stages through which passed evacuated.
N. N. Burdenko at the beginning of the first world war, when there was such medical records, has calculated the number of bandages undergone 2000 wounded during two days after the injury. It turned out that 55% of those injured were tied 4-5 times: due to the lack of medical documents fixing the nature of injury and already his assistance, had to take off the bandage on health posts just for the sake of further diagnosis. That disturbed unnecessarily important for wound healing principle of peace, created the conditions for re-infection of wounds, was irrational overloading staff.
Remains firmly in the system of staging treatment typical of the Soviet Army, the principle of timely medical assistance due to the rational location of clinics and hospitals and, as mentioned above, fastest delivery to them of the wounded and sick (with account of combat conditions, and the health and needs of victims in care). In modern conditions when the frequency of the variability of military and medical situation is of great significance maneuver forces and means of medical service in order to provide timely assistance to victims. Of great importance to ensure the timely provision of medical care has also medical sorting played on the stages of evacuation. In the process of this sort, in particular, is determined by the order of rendering assistance to the victims, as well as the order of their evacuation.

To receive the wounded (patients) and provide them with medical care in the system of staging treatment of evacuation routes are deployed clinics, hospitals (see), or groups of hospitals; they are called the stages of medical evacuation. Each clinic or hospital deployed (in tents, huts, shelters, buildings) in compliance with the General concept and in accordance with those tasks that must be performed by personnel on the stages of medical evacuation. To this end they created functional units: for the reception and sorting of the wounded and sick (sorting post, the reception and sorting office); to process requiring decontamination, decontamination and sanitary treatment (Playground or the office of the special treatment); for isolation of infectious patients or suspect infectious diseases (insulator); to provide medical care (dressing, operational, resuscitation and other); to hold on to the lightness or heaviness of the state (the hospital office, the team convalescent); waiting for evacuation (emergency Department). Depending on the purpose of the stage and the amount of assistance provided to the degree of development of the listed functional divisions different. So, on the stages, intended for rendering first medical aid, equipped with a minimal number of functional units, on the stages, where is qualified medical assistance, are, as a rule, all or most of these units. The main stages of medical evacuation are regimental medical center (MFC), medical and sanitary battalion (field hospital), individual medical detachment (OMO), private hospital or group of hospitals - the front and rear of the hospital database. RAP is intended for rendering first medical aid; medical battalion and OMO - for the immediate provision of skilled medical care; hospitals is to provide qualified and specialized help. Depending on the situation the volume of aid on the listed stages may be reduced or expanded.
The principle of staging treatment continues in the present. However, in modern conditions when applying the enemy rocket and nuclear weapons and other weapons of mass destruction may not always be saved system staging treatment with evacuation on purpose in those traditional forms that were practiced in the years of the great Patriotic war. The occurrence of the centers of mass of the sanitary losses (see Sanitary losses troops) with prevalence among the victims of severe combined lesions will require medical chiefs of decision making are somewhat different from the usual pattern of staging treatment. So, in the event of the centers of mass of the sanitary losses, for example in the offensive, sometimes you find more acceptable nomination to the pockets of a sufficient number of medical institutions for medical care and subsequent treatment of the victims on the spot. There are even cases when due to the mass popularity of sanitary losses in certain circumstances, the provision of qualified assistance to the affected will be impossible and would have to be evacuated directly to specialist hospitals of RAP or sites of massive losses.
However, the basic principles of the system of staging treatment in the conditions of modern war are still relevant in all cases, when the healing process will be divided according to the stages and implemented in conjunction with the evacuation. Cm. Medical and emergency supplies for troops, the Medical service of Armed Forces Medical support of the Armed Forces, medical Evacuation.