Trunkey Donald D
Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L223, Portland, OR 97239, USA.
World J Surg. 2008 Aug;32(8):1583-604. doi: 10.1007/s00268-008-9522-z.
Tom Friedman, in his book,"The World is Flat," makes a very persuasive argument that our current economic policy transcends national boundaries. Friedman describes various processes that prove his point. These include workflow software, open sourcing, outsourcing, off-shoring, supply chaining, in-sourcing, and informing. The United States already outsources surgery. In this article, I give the retail surgical rates and discount rates of the US, and compare them to that of the same surgery in India, Thailand, and Singapore. Supply chaining is another example that applies to the field of medicine, particularly pharmaceuticals. Most pharmaceutical firms are located in developed countries, but 80% of the pharmaceuticals are manufactured in developing countries. A phenomenon that may be unique to the United States is that we off-shore some of our diagnostic capabilities, primarily during out nighttime hours. Under the rubric of "Nighthawk," X-rays, including CT scans, are digitized and sent to Australia, Spain, and other countries during our nighttime hours. A diagnosis is made and sent back to the referring hospital in the US, usually within 30 minutes. I think an argument can be made that almost all of the issues that Friedman talks about in his book, apply to the field of medicine. Trauma care is a microcosm of medicine and uses most of the resources shared by other specialties. The trauma patient has to be identified and ambulances called, usually by 911 or similar numeric systems in other countries. The patient is transported to an emergency room, and if the injury is severe, admitted for acute care, which often requires surgery, intensive care, and ward care. When possible, the patient is discharged home, but is often sent to a rehabilitation facility or a nursing home. To improve trauma care and outcome, surgeons have turned to the organization and system approach that has been so successful in military situations.
An extensive review of the surgical and public health papers relating to trauma was carried out. This article is an inventory of how trauma systems are progressing in different countries and whether they are effective. Some of the pitfalls that globalization may bring are also discussed.
For the last 100 years, there has been gradual improvement in care of the civilian patients, as a system approach similar to the military care of injured patients has been introduced and matured. These systems include prehospital care, acute care, rehabilitation; ideally, using a public health approach, preventive components are also utilized. Research is another component that is key in improving patient outcomes.
汤姆·弗里德曼在其著作《世界是平的》中提出了一个很有说服力的观点，即我们当前的经济政策超越了国界。弗里德曼描述了各种证明他这一观点的过程。这些过程包括工作流软件、开源、外包、离岸外包、供应链、内包和信息传播。美国已经将外科手术外包。在本文中，我给出了美国的零售手术费率和折扣率，并将它们与印度、泰国和新加坡相同手术的费率进行了比较。供应链是另一个适用于医学领域，尤其是制药领域的例子。大多数制药公司位于发达国家，但80%的药品是在发展中国家生产的。美国可能独有的一种现象是，我们将一些诊断能力进行离岸外包，主要是在夜间。在“夜鹰”的框架下，包括CT扫描在内的X射线在夜间被数字化并发送到澳大利亚、西班牙和其他国家。然后做出诊断并发送回美国的转诊医院，通常在30分钟内。我认为可以说弗里德曼在他书中谈到的几乎所有问题都适用于医学领域。创伤护理是医学的一个缩影，使用了其他专科共享的大部分资源。创伤患者必须被识别出来，通常通过911或其他国家类似的数字系统呼叫救护车。患者被送往急诊室，如果伤势严重，则住院接受急性护理，这通常需要手术、重症监护和病房护理。如果可能，患者会出院回家，但通常会被送到康复机构或疗养院。为了改善创伤护理和治疗结果，外科医生转向了在军事情况下非常成功的组织和系统方法。
对与创伤相关的外科和公共卫生论文进行了广泛的综述。本文是对不同国家创伤系统进展情况及其是否有效的一份清单。还讨论了全球化可能带来的一些陷阱。
在过去的100年里，随着一种类似于军队对受伤患者护理的系统方法被引入并成熟，平民患者的护理有了逐步改善。这些系统包括院前护理、急性护理、康复；理想情况下，采用公共卫生方法，还会利用预防措施。研究是改善患者治疗结果的另一个关键因素。
