Doctor Miklosh Bala | Department of Surgery, Director of Trauma, Hadassah Medical Centre, Jerusalem, Israel
Your parents are from Hungary, you were born in Russia, went to medical school in Moscow, are now living in Israel, and can converse in English. You are well-travelled, but could you tell us about your experiences at medical school in Russia?
It was very good because I went to the best medical school in the whole of the Soviet Union. I guess I got a good education there in my 6 years. After medical school, I worked for about a year in Moscow as a junior doctor and then I left for Israel. I did all my residency here in Jerusalem at the Hadassah Medical centre.
At what point did you decide you were going to be a surgeon? What was the attraction?
From the first day I decided to be a doctor really. It is the best way to help people; you do something, you have a result, and there is immediate satisfaction. I decided to devote myself to trauma care; it was not easy, but I still did it. After residency in general surgery I travelled to the USA for a fellowship at the world-renowned R Adams Cowley Shock Trauma Center in Baltimore, Maryland, USA. After 2 years, I came back to Israel and I started my career in trauma surgery. I have now been given the position of Director of Trauma Services.
What would you say it is about combining emergency surgery and trauma surgery that is appealing to you?
You might have a specialty interest but if a trauma patient comes in, be it a gunshot or knife wound, motor vehicle accident, or a perforated diverticulitis, you would be required to do those surgeries as well. Any form of surgery specialisation leads to improved skills. Trauma surgery became very much less operative because of different technologies and we now understand more about the trauma physiology. It’s a lot of intensive care work and a lot of angiography and such like. The emergency cases are very similar to the trauma patients in terms of physiology. It’s a different mindset; I think about physiology first, then about how to get the patient better, and then how to treat their anatomy. This is converse to elective surgery such as colorectal where, for example, you have your disease, you know how to take it out, and that’s it.
There’s a big move in surgery at the moment for Enhanced Recovery after Surgery (ERAS®). You don’t have that luxury unfortunately because you’re dealing with people who are acutely ill, though you can implement some of the changes such as maintenance of body temperature. What are your thoughts, given your specialty, about ERAS and how it plays into elective cases, and what elements can you bring to your surgery, given that you don’t have preoperative preparation?
I think it’s all about the quality of care. You must have some kind of quality control, even though patients are sick and severely ill, and the ERAS actually helps to maintain the flow of processes to make the right decision. So technically you do something that is not quite planned, but then you come to the point when you can actually switch to enhancement. By doing whatever you have to do for the patient, they are doing better from the beginning because of the multidisciplinary approach. If we have more quality assessment in emergencies, it would probably be better.
Personal audit is also a key component of monitoring your own successes and your morbidity, which is an inevitable part of the role. Could you tell us a bit about how you use personal audit?
It is not implemented enough here in Israel. I learnt that in the USA, and here we have tried to maintain some registry and move toward the care that is built under the set of guidelines. We spend a lot of time putting together guidelines with people who work abroad, such as the World Society of Emergency Surgery (WSES). I’m very active in that and we do publish a lot of guidelines for acute diseases related to surgery in order to try and make this happen.
You have previously mentioned the non-operative management of trauma; can you tell us some of the examples of noninvasive, or less invasive, management that is seen today?
We have seen the impact of moving away from operative to less invasive. Most of the trauma today is managed noninvasively. Even with trauma such as penetrating injury to the liver we have a lot of experience with treating non-operatively. We just feel that it’s better for patients. Sometimes you want to operate but it’s not about what you would like to do, it’s about what is best for the patient. Sometimes it’s better to keep your hands in your pocket than to open their abdomen and cause multiple postoperative complications.
The team approach for the management of trauma is critical; for example, interventional radiologists, critical care staff, and respiratory physicians are all involved. Who are the key team members for you, and do you have regular conferences in your hospital, such as tumour board, to evaluate the care of trauma patients?
We have trauma meetings every month. We have a national trauma society which I am the chairman of; that is a lot of responsibility as most often it is all about teaching. In our centre here in Israel, the general surgical department and trauma services are in charge of all trauma patients. We also cooperate with orthopaedics and the intensive care unit, although every department in the hospital should be involved in the case if it’s their specialty. For example, at this symposium I gave talks about major trauma, what to do about the rectal injuries etc. Our colorectal surgeons are involved in patient care by helping out the whole team with decision making. Some things they are doing better at than me!
For people who are not former surgeons or don’t see trauma, the general public image of what the emergency room is like is very different to reality. It should be a very calm, well-drilled team. Is that your experience?
We try not to be too loud and we respect others. The people know when a trauma case arrives, so they know who’s in charge. It makes things much, much easier because nobody is trying to be too hands-on before a decision is made by me or my partner, who is another trauma surgeon at the hospital.
Could you tell us a little bit about the mix of trauma that you see in Israel? Everyone is aware of the sadness in our world, such as terrorist incidents, but presumably there are the usual motor vehicle accidents etc. Are there any special kinds of trauma you see as a result of terrorist activities, for example blast injuries and such like?
For the past 20 years, we are more or less not in a period of mass casualty anymore. The years 2000-2004 were the bad days. It was 5 years of hard work every day, with terror attacks twice a week in Jerusalem, let alone the whole of Israel. It was good experience for the surgeon, but bad experience generally. These occurences went down slowly, and now we get so-called lone wolf attacks. Some people get consumed by any idea; for example, a few months ago, we had an attack of somebody who took his car and drove into a crowd to target soldiers and other security personnel. People were very badly injured, but it was a different type of injury. Unfortunately stabbing still exists here in the Old City, but it only happens occasionally.
On a day-to-day basis, we deal with falls in the elderly. I’m not saying it’s all geriatrics, but it does make up a majority. People that have even small impact trauma can get sick very quickly. However, intensive care has got much better in the last 20 years. So, we do still have a job in trauma, but it’s more emergency surgery.
You’re participating at the meeting here in Jerusalem, which is a joint effort between the Cleveland Clinic David G. Jagelman Memorial and the Israel Society of Colon and Rectal Surgery (ISCRS). Have you had a chance to spend any time at the meeting yet? Is there anything in particular that you’ve got your eye on in the programme that you want to see?
There’s a lot of things that are very important. For me personally, I am interested in the emergency cases and the discussion of new technologies that could improve daily surgical work. With elective surgery, it’s very important to be up to date.