“现实很少符合指导原则”：一项定性研究，探讨了医院医生在战伤处理中面临的挑战。
"Reality rarely looks like the guidelines": a qualitative study of the challenges hospital-based physicians encounter in war wound management.
机构信息
Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
出版信息
Scand J Trauma Resusc Emerg Med. 2018 Jun 27;26(1):52. doi: 10.1186/s13049-018-0517-y.
BACKGROUND
Globally, armed conflict is a major contributor to mortality and morbidity. The treatment of war-associated injuries is largely experience-based. Evidence is weak due to difficulty in conducting medical research in war settings. A qualitative method could provide insight into the specific challenges associated with providing health care to injured civilians. The aim of this study was to explore the challenges hospital-based physicians encounter in war wound management, focusing on surgical intervention and antibiotic use.
METHODS
Semi-structured, face-to-face interviews were conducted with physicians at a Jordanian hospital supported by Médecins Sans Frontières. The interviews were recorded, transcribed verbatim and analysed using content analysis with an inductive and deductive approach.
RESULTS
We found that challenges in war wound management primarily relate to protocol adherence. Protocols for the management of acute war wounds were adhered to on areas that could be considered commonly agreed principles of war wound surgery, such as the use of wound debridement and the evaluation of the systemic condition of the patient before initiating antibiotic treatment. We identified limitations imposed on the physicians that complicate or even hinder protocol adherence. Additionally, we identified factors associated with conscious deviations from the protocols.
CONCLUSIONS
We conclude that adherence to established protocols around the management of acute war wounds is difficult. We present aspects that may be considered when establishing clinical projects in similar contexts. The knowledge gained by this study could provide insights for the development of protocols or guidelines for wound management and antibiotic use in an unstable setting, such as a hospital in close proximity to armed conflict. We suggest the use of a grounded theory approach to further study the discrepancy between guideline recommendations and actual practice.
背景
在全球范围内，武装冲突是导致死亡和发病的主要原因之一。针对战争相关伤害的治疗主要基于经验。由于在战争环境中进行医学研究存在困难，因此证据较为薄弱。定性方法可以深入了解为受伤平民提供医疗保健所面临的具体挑战。本研究旨在探讨在战争创伤管理中，医院医生所面临的挑战，重点是手术干预和抗生素的使用。
方法
我们对一家由无国界医生组织支持的约旦医院的医生进行了半结构化的面对面访谈。访谈进行了录音，逐字转录，并使用归纳和演绎相结合的内容分析法进行分析。
结果
我们发现，战争创伤管理中的挑战主要与遵守协议有关。在急性战争创伤管理方面，遵循了被普遍认为是战争创伤手术基本原则的协议，例如使用清创术，以及在开始抗生素治疗前评估患者的全身状况。我们确定了对医生造成限制的因素，这些因素使遵守协议变得复杂甚至受阻。此外，我们还确定了与协议偏离有关的因素。
结论
我们得出结论，遵守急性战争创伤管理方面的既定协议具有一定难度。我们提出了在类似背景下开展临床项目时可能需要考虑的方面。这项研究获得的知识可以为在不稳定环境（如临近武装冲突的医院）中制定创伤管理和抗生素使用的协议或指南提供参考。我们建议采用扎根理论方法进一步研究指南建议与实际实践之间的差异。
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