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【创伤外科】第1期(含ppt)。第2期ing:创伤首诊与处理(此处仅有翻译,精彩请见原帖) [精华]

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楼主 道可道非常道
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这个帖子发布于14年零10天前,其中的信息可能已发生改变或有所发展。
此帖专门针对bo兄的讲座进行翻译和校对,翻译不是目的,此帖主要是为英语稍欠的战友方便同步交流而设,望大家积极在原帖就专业问题积极交流。当然也欢迎对医学英语感兴趣的借此机会相互交流。

先附上原帖地址,针对创伤外科专业的问题,请大家在原帖进行交流!:D
http://www.dxy.cn/bbs/post/view?bid=48&id=8002631&sty=1&tpg=1&age=0

-------------------------------------------------

重要说明:为避免重复翻译,请兄弟们先认领后翻译。认领后请兄弟们及时回帖说明,完成后再进行编辑自己的原帖。:)

请认领一整篇或几段的战友,也将译文先附在相应段落的下方,以方便大家对比讨论。当然,同时考虑到整篇和分段翻译有一定不同,可以在分段翻译后,将自己的整篇译文附上,毕竟段落需要精确,全篇需要流畅和统一。:)

1、各位兄弟在翻译中自己拿不准的词统一用红颜色标注,方便校对及大家讨论修正!

2、已经有战友认领的部分原则上不建议重复认领,只针对已经翻译好的内容进行讨论修正。当然,确实有独到见解的,完全可以提出自己的版本!

2、为了方便大家能一目了然进行认领翻译和浏览,我会在顶楼提供相关链接。
(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)
(请点击下方蓝色文字直接进入,或者在跟帖中找到相关内容)

相关内容链接

第2期英文原文

第2期正文翻译

第2期互动交流原文

第2期互动交流翻译

第1期相关内容链接(已基本完成)

医学术语总结专贴(感谢li_88_xin战友的细心总结)

(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)(f)
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精彩课件

讨论完成后,会在此帖,完成中英文共同版的课件,包括专题中的正文、问答、图片和病例讨论。

luohui961是非常热心,也是软件方面的高手,课件制作的事就麻烦luohui961战友了!欢迎下载并提供建议。

点击进入课件下载页面(该ppt图文并茂、中英互译、动静结合)
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道可道非常道 编辑于 2007-01-30 14:20
  • • 不会基础实验是否就已经无缘医学博士了呢
楼主 道可道非常道
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红色为已认领部分。


--------------------第一部分-----------------
Trauma surgery
Chapter one
Trauma surgery

(1)Trauma surgery is a relative new subspecialty of General surgery. In 1976, an orthopedic surgeon and his family crashed an airplane, the wife died immediately and his children were in critical condition. In the hospital, he found he could provide better care for his children at the field with limited resource than the primary care facility, which told us something was wrong with system. That was the initiation of trauma surgery. Trauma surgery was formed and started to function in 1980 and has become more and more sophisticated. If you have such experience in china, such as your family, relatives, friends involved in accidents or other traumatic injuries, you feel you can provide better care than the hospital, and then there is a problem of the system. Then we need trauma surgery, this subspecialty of general surgery in china. Does anyone have such experience?

(2)Trauma is very common medical problem in the USA, as well as in china. It is the leading cause of death in the first forty years of life (1 to 44 yr). About 150,000 deaths annually in the US. The death is distributed as a trimode. First peak: seconds to minutes at the scene, generally resulting from lacerations from brain stem, heart, aorta and large vessels. this is no-savable. Second peak: minutes to several hours after injury, resulting from hemopneumothorax, ruptured spleen liver, pelvic fractures..... This is the time that general surgeons can make a difference. Also it’s called the “golden hour”. Third peak: days after injury. Resulting from sepsis, MOFS

Trauma surgeon

(3)Trauma surgeon is a general surgeon. In 5 years of training of general surgery, a general surgeon should be very comfortable taking care any trauma patients at trauma bay. The trauma surgeon is the key person to save the trauma patient. You have many people around you, residents, nurses, respiratory technicians, ER doctors, anesthesia (see the attached picture). You are the one making quick assessment, operative decisions. Most Trauma surgeons are very aggressive. If you want to do critical care, you need one year fellowship of critical care at big trauma center, which will make you a complete trauma surgeon. After the fellowship, you are qualified to take care of critical patients in the ICU.

(4)Trauma surgeons are:
Fast, composed and organized
Thinks ahead and predicts
Decisive Make decisions
Recognizes the problem
In any cavity (not just a Can operate belly surgeon)
Nice guy/girl!!!
At trauma bay, facing a trauma patient: the main questions are:
Bleeding? Is there ongoing
Is there an injury requiring an operation?
for further investigation? Is there a need
If the patient is bleeding, stop the bleeding; if the patient’s dying, don’t let him/her die.

--------------------第二部分-----------------
(1)trauma system, Trauma center, and trauma bay

The elements necessary to establish a trauma system include four primary patients needs: 1. access to care, 2. prehospital care, 3. hospital care (trauma center), 4. Rehabilitation.

access to care: this part depends on the police department and fire department. our trauma center has a very close relationship with those two departments. when there is a trauma, police or fire fighter arrive first to rescue the patients at the scene.

triage, derived from French word "to sort". prioritizing victims into categories based on severity of injury, likelihood of survival, and urgency of care. the goal is to identify high risk injured patients who would benefit from the resources available in a trauma center.

(2)prehospital care: the principle of prehospital care are: secure the area, determining the need for emergency treatment, initiating treatment, communicating with medical central and rapidly transfer patients to a trauma center. most fire fighter are the EMS guys (emergency medicine services). they know how to intubate the patient, decompress a tension pneumothorax, start IVs. all these are prehospital care. after the police and fire fighters find the patient, started some basic treatment, they will call the emergency department of a level trauma center, telling the trauma center they have patients coming in.

(3)transportation: flying ambulances or helicopters.

hospital care: after emergency department is notified, then we, trauma team will be paged with codes, everybody of the trauma team arrives at trauma bay, waiting for patients come. this is the start of hospital care.

after the treatment in the hospital, a lot of patients need rehabilitation which is the fourth part. we have at least three rehabilitation institutions in town.
-------------------第三部分------------------
(1)trauma center

The trauma center serves to integrate the trauma care system by providing local or regional leadership. By providing a network of trauma care facilities within the system, an inclusive system can function to provide a range of care to meet patient needs. Trauma centers are currently categorized by level, with Level I referring to those facilities with the greatest resources.

(2)Level I Trauma Center. The Level I trauma center is a tertiary care hospital that demonstrates a leadership role in system development, optimal trauma care, quality improvement, education, and research. It serves as a regional resource for the provision of the most sophisticated trauma care, from resuscitation through rehabilitation. Level I trauma centers address public education and prevention issues on a regional basis and provide continuing education for all levels of trauma care providers.

(3)In level I trauma center, there is always a in-house trauma surgeon, 24-7(24 hours a day, seven days a week). Also it is required that the hospital has neurosurgeons, trauma orthopedic surgeons, plastic surgeons, hand surgeons, cardiothoracic surgeons available when needed. Besides trauma surgeons, there must be a surgical / trauma ICU run by trauma surgeons or anesthesiologists who had one year training of critical care and certified by critical care medicine. our trauma center is a level I trauma center

(4)Level II Trauma Center. The Level II trauma center also provides definitive care to the injured and may be the principal hospital in the community. Its approach to trauma is generally not as comprehensive as the Level I facility, and graduate education and research are not required.

(5)Level III Trauma Center. A Level III trauma center serves a community that lacks Level I or II facilities. Maximum commitment is required to assess, resuscitate, and, when necessary, provide definitive operative therapy. For the major trauma patient, the principal role of the Level III center is to stabilize the injured patient and effect safe transfer to a higher level of care. Transfer agreements and protocols are essential in a Level III trauma center.

(6)Level IV Trauma Center. A Level IV trauma center is expected to provide the initial care to an acutely injured patient despite limitations in resources. As with a Level III center, transfer agreements and protocols must be in place. Since definitive trauma care is usually not available at a Level IV center, a well-practiced mechanism must be in place to ensure prompt transfer to a higher level of care.
Trauma team

(7)trauma surgeon: team leader
trauma chief resident: primary assessment, putting central lines, Arterial line, chest tubes, emergent surgery: thoracotomy, stop bleeding
trauma senior/ junior resident: support trauma chief, expose the patient body....document the finding.

other member:
ER doctor (1-2): intubation
trauma bay nurse: give medication
technician: peripheral IV, FOLEY, NGT, find surgical instruments
respiratory therapist: ventilator management
X-ray technician
OR nurse: trying to find out what surgery to do and set up the room
Anesthesia: help intubation, set up the room

as shown in the graph, others should stand out side the line except the key players of the trauma team.

now you know why the picture I showed before was a bad organization. if you have too many people around the bed, they will be just in your way.
------------------第四部分----------------------
(1)trauma codes:

Different hospital has different trauma code. we have trauma red, trauma white and trauma green. similar to the three category fish0220 mentioned. trauma team only go to trauma bay for trauma red and white. ER doctors take care of trauma green.

TRAUMA RED

• Trauma arrest
• Compromised airway
• BP < 90, or shock in peds
• Head injury & GCS < 8
• Amputation proximal to wrist or ankle
• Burn > 15% (2° or 3°) or with respiratory distress, with trauma
• Major vascular injury
• Intubated
• Limb paralysis
• Penetrating injury to torso, head, neck, or extremity with pulse deficit
• Transfer from another hospital receiving blood to maintain vitals
• Emergency physician discretion
TRAUMA WHITE

• One or more proximal long bone fractures
• Pelvic fractures
• Pregnancy > 24 weeks with suspected abdominal or pelvic injury
• Transfer from another facility for specialized trauma care
• Flail chest
• Extrication > 20 minutes
• Ejection from transport
• Death of another person in same passenger compartment
• Age > 65 with any other "green" criteria
• Loss of consciousness of > 2 minutes
• Others at emergency physician discretion

(2)TRAUMA GREEN

• "Mechanism-only" patients with normal level of consciousness, good vital signs, and no obvious serious injury. (Note that several "mechanisms" are listed specifically as "whites".)
• "Mechanism-only" cases may be upgraded to the WHITE level if complicated by extremes of age or serious pre-existing condition.
• Some trauma "mechanisms" are not defined in the prehospital trauma triage decision scheme; mechanisms similar to those defined may qualify as a GREEN. This includes blunt assaults

-----------------------(第五部分)--------------
(1) trauma bay procedures

all the procedures I mentioned are very important for any patients, esp. trauma patients. if you just see it and have never tried, you probably don't want to do it alone. there are serious complications of those procedures.

intubation: very important to protect the airway, if you intubate into the esophagus or can't get the tube in, you may kill the patient.

chest tube: I have seen residents put into the liver and spleen

cricothyroidotomy: you can cause a lot of bleeding. the blood gets into the trachea, block the airway, can also kill the patient and worst thing is: there is no other way. if you do it, you gotta do it right. there is no room of mistakes.

the best way to get better is to practice. you can ask anesthesia to let you intubate your patient in the OR for elective cases. that's how I learned intubation. try to do chest tube when you are on Cardiothoracic rotation. just try all the possible to practice and you will be good and comfortable at it. then you can function under pressure for the trauma patients.

(2)central line:

central line for Resuscitation, TPN, medication (when they are several drips, some of the medication can be given through peripheral IV) ...... central lines are also potentially dangerous. sometimes the procedure can kill the patient too.

using internal jugular vein: injury to the carotid artery, resulting in stroke.

subclavian vein: injury to subclavian A, an nominate A, may need median sternotomy to fix it.

Femoral vein is relative safer place. however, if the patient has IVC injury, femoral line work, because transfusion or IV fluids just bleeds out.

central line is very useful tool to help patient. any general surgery residents should be good at it.

if you guys are not familiar with those technique, I can discuss how to do it.

Would you like to illustration of those procedures? please leave me a note for this question too.
------------------(第六部分)------------------
(1)trauma/general surgery basic skill procedure:

I’d like to talk about one important airway management first before I talked about lines.

1 SURGICAL CRICOTHYROIDOTOMY
A. Place the patient in a supine position with the neck in a neutral position. Palpate the thyroid notch, cricothyroid interval, and the sternal notch for orientation. Assemble the necessary equipment.
B. Surgically prepare and anesthetize the area locally, if the patient is conscious. no anesthesia is need if patient's unconscious.
C. Stabilize the thyroid cartilage with the left hand and maintain stabilization until the trachea is intubated.
D. Make a transverse skin incision (2 cm, not too long) over the cricothyroid membrane, and carefully incise through the membrane transversely.
E. Insert the scalpel handle into the incision and rotate it 90° to open the airway as I showed before (A hemostat or tracheal spreader also may be used instead of the scalpel handle.)
F. Insert an appropriately sized, cuffed endotracheal tube or tracheostomy tube (usually a #5 or #6) into the cricothyroid membrane incision, directing the tube distally into the trachea.
G. Inflate the cuff and ventilate the patient.
H. Observe lung inflations and auscultate the chest for adequate ventilation.
I. Secure the endotracheal or tracheostomy tube to the patient to prevent dislodging.
J. Caution: Do not cut or remove the cricothyroid cartilage.
COMPLICATIONS OF SURGICAL CRICOTHYROIDOTOMY
1. Aspiration (eg, blood)
2. Creation of a false passage into the tissues
3. Subglottic stenosis/edema
4. Laryngeal stenosis
5. Hemorrhage or hematoma formation
6. Laceration of the esophagus
7. Laceration of the trachea
8. Mediastinal emphysema
9. Vocal cord paralysis, hoarseness
10 DON'T DO IT FOR CHILDREA LESS THAN 11 YEARS OLD. IT WILL CAUSE DIFORMITY OF THE LARYNX.

(2)Central lines

For the IV access, you always want to try peripheral IV first, use large bore IV catheters (16, 18 gauge catheter). in emergent case, needs large volume resuscitation, you can put central line quickly. femoral line is always a good start except you suspect patient has IVC injury.

there are three types of catheters for central line: cordless (single lumen, largest), double lumen and triple lumen catheter. if you have the kit (ARROW central line kit), you should have everything you need to do the line). for resuscitation of trauma patients, cords is preferred due the largest lumen, delivering resuscitation fluids fastest.

the following are explanation if central line through femoral vein, IJ (internal jugular vein), subclavian vein.

(3)FEMORAL VENIPUNCTURE: SELDINGER TECHNIQUE

A. Place the patient in a supine position.
B. Cleanse the skin well around the venipuncture site and drape the area. Sterile gloves and gown should be worn when performing this procedure.
C. Locate the femoral vein by palpating the femoral artery. The vein lies directly medial (about 1 cm area) to the femoral artery (nerve, artery, vein, empty space). A finger should remain on the artery to facilitate anatomical location and to avoid insertion of the catheter into the artery.
D. If the patient is awake, use a local anesthetic at the venipuncture site.
E. Introduce a large-caliber needle attached to a 10-mL syringe. The needle, directed toward the patient's head, should enter the skin directly over the femoral vein.
F. The needle and syringe are held 30 degree to the frontal plane.

G. Directing the needle cephalad and posterior, slowly advance the needle while gently withdrawing the plunger of the syringe.
H. When a free flow of blood appears in the syringe, remove the syringe and occlude the needle with a finger to prevent air embolism.
I. Insert the guidewire and remove the needle. Then insert the catheter over the guidewire.
J. Remove the guidewire and connect the catheter to the intravenous tubing.
K. Affix the catheter in place (i.e., with suture), apply antibiotic ointment, and dress the area.
L. Tape the intravenous tubing in place.
M. The catheter should be changed as soon as practical.
MAJOR COMPLICATIONS OF FEMORAL VENOUS ACCESS
1. Deep vein thrombosis
2. Arterial or neurologic injury
3. Infection
4. Arteriovenous fistula
(4)INTERNAL JUGULAR VENIPUNCTURE: MIDDLE OR CENTRAL ROUTE

Note: Internal jugular catheterization is frequently difficult in the injured patient due to the precaution necessary to protect the patient's cervical spinal cord.

A. Place the patient in a supine position, at least 15° head down (trendelenberg position) to extend the neck veins and to prevent an air embolism. Only if the cervical spine has been cleared radiographically can the patient's head be turned away from the venipuncture site.
B. Cleanse the skin well around the venipuncture site and drape the area. Sterile
gloves should be worn when performing this procedure
C. If the patient is awake, use a local anesthetic at the venipuncture site.
D. start with a 5 ml syringe and 22 gague need as a seeker needle. Introduce the needle into the center of the triangle formed by the two lower heads of the sternomastoid and the clavicle, aiming toward s the ipsilateral nipple. After you find the IJ, switch to a large-caliber needle with a 12 ml syringe repeat this step.

(another way to localize IJ is to use an ultrasound called SITERITE. you can mark the path of IJ with Siteite or even do the ultrasound guided venopuncture if you have this kind ultrasound machine)

E. After the skin has been punctured, with the bevel of the needle upward, expel the skin plug that may occlude the needle.
F. Direct the needle caudally, parallel to the sagittal plane, at a 30° posterior angle with the frontal plane.
G. Slowly advance the needle while gently withdrawing the plunger of the syringe.
H. When a free flow of blood appears in the syringe, remove the syringe and occlude the needle with a finger to prevent air embolism. If the vein is not entered, withdraw the needle and redirect it 5° to 10° laterally.
I. Insert the guidewire while monitoring the electrocardiogram for rhythm
abnormalities.
J. Remove the needle while securing the guidewire and advance the catheter over the wire. Connect the catheter to the intravenous tubing.
K. Affix the catheter in place to the skin (eg, with suture), apply antibiotic ointment, and dress the area.
L. Tape the intravenous tubing in place.
M. Obtain a chest film to identify the position of the intravenous line and a possible pneumothorax.
N. If you hit the carotid artery, pull the needle out and hold pressure for 5 minutes.

COMPLICATIONS OF CENTRAL VENOUS PUNCTURE
1.. Pneumo- or hemothorax
2. Venous thrombosis
3. Arterial or neurologic injury
4. Arteriovenous fistula
5. Chylothorax
6. Infection
7. Air embolism

(5)SUBCLAVIAN VENIPUNCTURE: INFRACLAVICULAR APPROACH

A. Place the patient in a supine position, at least 15° head-down (trendelenberg position) to distend the neck veins and prevent an air embolism. Only if a c-spine injury has been excluded can the patient's head be turned away from the venipuncture site.
B. Cleanse the skin well around the venipuncture site and drape the area. Sterile gloves should be worn when performing this procedure.
C. If the patient is awake, use a local anesthetic at the venipuncture site.
D. Introduce a large-caliber needle, attached to a 12-mL syringe with 0.5 to 1 ml saline or air, 2 cm below the junction of the middle and lateral thirds of the clavicle, right below the turning for the clavicle.
E. After the skin has been punctured, with the bevel of the needle upward, expel the skin plug that may occlude the needle.
F. The needle and syringe are held parallel to the frontal plane.
G. Direct the needle medially, slightly cephalad, and posterior behind the clavicle toward the posterior, superior angle to the sternal end of the clavicle (toward finger placed in the suprasternal notch).
H. Slowly advance the needle while gently withdrawing the plunger of the syringe.
I. When a free flow of blood appears in the syringe, rotate the bevel of the needle caudally, remove the syringe, and occlude the needle with a finger to prevent an air embolism.
J. Insert the guidewire while monitoring the electrocardiogram for rhythm abnormalities. Then remove the needle while holding the guidewire in place.
K. Insert the catheter over the guidewire to a predetermined depth (tip of catheter should be above the fight atrium for fluid administration).
L. Connect the catheter to the intravenous tubing.
M. Affix the catheter securely to the skin (eg, with suture), apply antibiotic ointment, and dress the area.
N. Tape the intravenous tubing in place.
O. Obtain a chest film to identify the position of the intravenous line and a possible pneumothorax.

complications are same as IJ.

COMPLICATIONS OF CENTRAL VENOUS PUNCTURE
1.. Pneumo- or hemothorax
2. Venous thrombosis
3. Arterial or neurologic injury
4. Arteriovenous fistula
5. Chylothorax
6. Infection
7. Air embolism

MORE ABOUT central lines: if you know how to do lines at one site, you can apply the same principles for other sites. very important to review the anatomy on the book or even in the anatomy lab.

please let me know if you have any questions.

see you next time

Bo

-------------------(第七部分)-------------------
(1)Trauma Bay

Trauma bay is a part of ER specifically for trauma patients. trauma patients don't go through the regular procedure to see a doctor, instead, they transported directly from ambulance or helicopter to trauma bay.

The setup of ER is different too between china and US. Only ER attendings and resident working in the ER. they do all the work up for patients, figure out what's going with the patients, if patients have surgical problems, they will call surgery for consult. so no surgical residents or attending sitting in the ER, instead, surgeons are doing their own work until they are paged, then they will go to the ER see patients。

(2)HOW SET UP TRAUMA BAY:

trauma bay is a very important place for trauma surgery. it is the place we see trauma patients first time. also it is the place to do emergent procedures to save dying patients, such as: intubation, chest tube, resuscitation, emergent thoracotomy, cricothyroidectomy...... so the set up is very important. the worst thing is when you need to cut the patient you can't find a knife.

also, trauma bay should be very close to the operating room (OR). When need move the patient to the OR, you can do it within a minute. we have four trauma bays right next to OR。

(3)items needed for trauma bay setup.

1. a bed: it should be mobile, you can move it very easily and change patient position easily

2. Operating lights over the bed
3. cardiac monitor (including EKG, BP, SaO2)
4. A-line set up
5. O2, and wall suction
6. defibrillator
7. central line kits
8. pressure transfusion set up
9. warmer for warm fluids
10. warmer to keep warm blanket
11. FAST machine( Focal Assessment with Sonography for Trauma): it is an ultrasound machine, has replaced DPL)
12. X-ray machine
13. X-ray reading monitor
14. gloves (both sterile and nonsterile), masks, gowns, shoe-covers
15. procedure trays: including intubation, cricothyroidotomy, tracheostomy, chest tube, thoracotomy.....
16. bare hugger (to warm the patient)
17. NGT
18. Foley。

(4)
we are getting to the end of the first discussion. I plan to start the second discussion of trauma which is "initial assessment and management for trauma patients" some time next week.

one more I’d like to discuss before the ending is the concept of trauma.

three underlying concepts of trauma management which may be difficult to accept initially:

1. the most important concept is to treat the greatest threat to life first.
2. the lack of a definitive diagnosis should never impede the application of an indicated treatment
3. A detailed history was not essential to begin the evaluation of an acutely injured patient.

The result was the development of the "ABCDE" approach to the evaluation and treatment of the injured, which will be the core of the second discussion of trauma surgery.

(5)Surgical/Trauma ICU

Another important component of trauma center is ICU. in our hospital, we have CCU (Coronary Care Unit), CT ICU (for cardiothoracic patients) Medical ICU, Surgical / trauma ICU which has 20 beds. if we have more patients we use Medical ICU beds. ICU is a very important part to treat trauma patients. everyday, we have one trauma attending or an anesthesiologist doing rounds with three residents. all the attending had their training of critical care and certified. besides doing rounds on the ICU patients, trauma surgeons also operate on those ICU patients if they need operations, such as the finishing damage control operation, second look, wash out, tracheostomy, gastrostomy, decompression laparotomy........ that's the difference between ICU trauma attendings and ICU anesthesia attendings.

nursing staff are very important. we have 1:1 or 1:2 nurse to patient ratio. they do a lot of work: such as wound dressing change, Foley, NGT, dobhoff (nasoduodenal tube) ........

since the discussion of ICU is another huge topic, I don't want to get into it too much.
2007-01-10 03:03
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道可道非常道 编辑于 2007-01-30 13:32
  • • 继续读博还是回家工作
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2007-01-10 10:29
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亲密飞翔 编辑于 2007-01-10 13:24
  • • 教育部:今年国家定向培养免费医学生 ,你会报考吗?——回帖
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来顶波兄和道兄!
飞翔战友做得很好,以后会多来这里,严密关注中!:)
2007-01-10 12:07
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