Background: 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. Materials and methods: 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. Results and conclusions: 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.
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