It was 9:00 pm, and Israeli surgeon Ilan Schrier, MD, and his trauma team sprang into action to save a woman who had been stabbed in the heart by a mugger. Her systolic blood pressure read 60 (mm Hg). She was on the verge of death. Within seven minutes of arrival, Dr. Schrier and his trauma team opened her chest. Her pericardial sac was brimming with blood. She was going through cardiac tamponade. They found a puncture in her left ventricle and quickly stitched it up. This lifesaving procedure was not performed in Israel—it happened at the University of Miami (UM) Ryder Trauma Center, FL.
Dr. Schrier is training to become an expert trauma surgeon with a fellowship at the UM Ryder Trauma Center. Later this year, he will have completed a one-year fellowship and returned to the Rabin Medical Center in Petah-Tikva, one of six Level I trauma centers in Israel, and will work alongside the facility’s director, Michael Stein, MD, FACS.
Israel does not have the same rate of continuous penetrating trauma as the U.S., despite the violence associated with the Israel-Palestine conflict. “In Israel, we barely see gunshot wounds,” Dr. Schrier said. “In Miami, we see them every day.” Because penetrating trauma is uncommon outside of the U.S., aspiring trauma surgeons in Israel and other countries must train in high-volume centers abroad to acquire the skills needed to perform trauma surgery.
This article focuses on Ryder’s efforts to contribute to global trauma care training. Ryder, one of several U.S. health care facilities that train trauma surgeons from around the world, has been particularly involved in training trauma surgeons from Israel through an initiative proposed by Kenneth L. Mattox, MD, FACS, an active member of the American College of Surgeons (ACS) Committee on Trauma (COT) and Past First Vice-President of the College. The development of the Ryder program is described, which offers a blueprint for other academic medical institutions interested in training surgeons to provide specialized care outside of the U.S.
Trauma and disaster relief
The UM Ryder Trauma Center has an active international trauma training program, and the institution’s trauma surgeons and residents have been involved in disaster response and trauma system development efforts in Haiti, Brazil, and Argentina.
Dr. Ginzburg, a co-author of this article, was the international director of Project Medishare in 2010 when a catastrophic earthquake struck Haiti, killing more than 160,000 and displacing close to 1.5 million people. In this role, he served as the informal field hospital coordinator for the World Health Organization the first 72 hours after the catastrophe took place. An affiliate of the UM Medical School, Project Medishare used four large event tents to establish one of the early field hospitals for trauma care after the earthquake. This tent-turned-critical-care-hospital was established at the Port-au-Prince airport with 250 to 300 beds.
Dr. Ginzburg subsequently transferred to the 80-bed Hospital Bernard Mevs in Port-au-Prince—one of the two current Haitian-run trauma centers in the city. The facility provides care to trauma patients in Haiti to this day.
The UM Ryder Trauma Center also assisted the Brazilian government in establishing two new trauma centers in Rio de Janeiro. The centers were established to provide care at the 2014 FIFA World Cup and emergency services at the 2016 Summer Olympics. This latter effort was led by Antonio C. Marttos, Jr., MD, associate professor of surgery and co-director, William Lehman Injury Research Center, UM. The two hospitals continue to function as trauma centers, one of which, Hospital Estadual Alberto Torres, is a standalone facility.
The UM’s global trauma relief efforts in Argentina include a partnership with Fundación Trauma in Buenos Aires that, over the last six years, has resulted in the launch of an organized trauma system, including the development of the first electronic trauma registry for the region. This registry contains data on nine trauma centers that serve a population of more than 12 million Argentinians. This registry is compliant with the International Classification of Diseases, 10th Revision, and has been used in multiple academic research projects and by the ministry of health in the development of health policy. The Argentine government has since signed a memorandum of understanding to work with Fundación Trauma to expand national use of the database.
In addition, UM Ryder Trauma Center organized and continues to host the Panamerican Trauma Society weekly telemedicine grand rounds. Each Friday, up to 20 different international centers participate in a trauma case presentation.
Launch of Israel initiative
We were honored in 1992 when Dr. Mattox contacted Robert Zeppa, MD, FACS, then-chair of surgery at UM, to see if Ryder Trauma Center would assist in training an Israeli trauma surgeon. Considering UM Ryder Trauma Center’s experience helping countries build and sustain trauma systems, we felt well-equipped to develop this program, which formally launched two years after the first Israeli fellow, Mauricio Lynn, MD, returned home in 1998. This initiative has proven invaluable in enabling Ryder to conduct the outreach programs described previously.
Since the program’s inception, 16 Israeli surgeons have completed trauma fellowships in the U.S., including one at Ben Taub Hospital, Houston, TX, where Dr. Mattox is chief of staff and surgeon-in-chief; two at the University of Pittsburgh, PA; two at the Maryland Institute for Emergency Medical Services Systems, Baltimore; and 11 at the UM Ryder Trauma Center. Of these 16 Israeli trauma surgeons, nine practice in Israel. Dr. Schrier will be the 10th surgeon to return to Israel after he completes the program this year. Of the remaining six surgeons, one chose to remain in the U.S., and the other five have focused on their general surgery practices.
The Israeli fellows have no impact on the number of fellowships available to U.S. surgeons through Ryder’s formal trauma training program. However, they do rotate on the same services, receiving the same caliber of training as UM’s formal Residency Review Committee fellows. The Israeli fellows participate in the same critical care, acute care surgery, and trauma service lines, and conduct research alongside our U.S. fellows. Therefore, Israeli fellows are required to pass the U.S. Medical License Examination (USMLE) before they can practice and provide clinical care in our program.
Because these are formal fellowship positions, the hospital regards these fellows as residents and provides them with a sixth- and seventh-year salary line. More than 90 percent of the Israeli trainees have successfully completed the two-year surgical critical care/trauma fellowship.
To assess the present trauma care system in Israel and determine the ongoing need for the training program, in 2015 the members of the UM Ryder Trauma Center team interviewed the directors at the six Level I trauma centers in the country. All of the directors indicated that the greatest need was for more surgeons formally trained in trauma care. Most Level I hospitals in Israel have just one dedicated trauma surgeon on staff; the exceptions are Rambam Medical Center in Haifa and Tel Aviv Medical Center, both of which have two trauma surgeons on staff.
“It is a one-man show,” said Prof. Gadi Shaked, director of Soroka Medical Center in Be’er Sheva, the only Level I trauma center that serves Israel’s southern populations. Trauma directors are on-call around the clock, but are rarely available 24/7 a week due to other professional time commitments, including teaching. The limited availability of trauma directors puts patients who require immediate complex operations at risk. Israel needs at least 10 more trauma experts, according to co-author Yoram Klein, MD, former chairman of the Israeli Trauma Society and head of Sheba Medical Center, Tel-Hashomer, Ramat-Gan.
The challenges facing Israel’s trauma care system are better understood with the realization that the system is in its early stages of development. Even though Israel has experience with trauma that covers eight wars, two Palestinian intifadas, and thousands of internecine attacks, an organized trauma system was nonexistent until the early 1990s.1
National recognition of the need for a continuous trauma system by the Revach Committee in the late 1980s propelled the Ministry of Health to implement major organizational changes, equipment updates, and staff training.1,2 The new system was modeled on the U.S. trauma system but was adapted to meet Israel’s needs.1 Six Level I trauma centers were designated according to ACS COT standards, centralizing severe trauma patients.3 A national trauma registry that included injury severity score was assembled.3 All medical personnel in trauma and emergency services were required to take the Advanced Trauma Life Support® (ATLS®) course.4 Amidst these changes, top general surgeons volunteered to complete U.S. trauma fellowships.5 These surgeons serve as the current trauma directors.
The trauma directors we interviewed, however, fear that the momentum of the 1990s has subsided and that recruitment of new surgeons to train outside of Israel is unsustainable. “There is no new generation ready to replace the aging trauma surgeon generation, which is alarming,” said Hany Bahouth, MD, director of Rambam Medical Center and chairman of the Israeli Trauma Society.
While U.S. Level I hospitals are open to training Israeli fellows, the directors said that there are no incentives for formal trauma training. In Israel, the salary of a dedicated trauma surgeon or director is the same as the salary of a general attending surgeon, but, unlike other senior surgeons, trauma surgeons are unable to supplement their income with private practice. In addition, the lifestyle is less than ideal because they are on-call 24/7. The time spent training and the requirement to pass the USMLE inhibit formal trauma training for many surgeons. Essentially, many Israeli surgeons feel that a trauma fellowship in the U.S. is arduous work for the same pay.
To incentivize recruitment, one solution would be to raise the salary of expert trauma surgeons. Drs. Klein and Bahouth, however, described trauma care as one of the least recognized divisions of medicine in Israel. Only two Level I hospitals have dedicated trauma beds. Expert trauma surgeons even provide specialty services on the side because they are paid four to five times more for private practice. More recognition, according to Drs. Klein and Bahouth, would allow trauma care to become more organized, raise salaries, and attract residents. A fellowship does exist in Israel, but the current program does not expose fellows to enough penetrating and operative cases.
Dr. Klein believes that adding a three-month operative experience in the U.S. would correct this gap. This proposal, however, lacks funding. The health care system in Israel provides a low volume of trauma services on an everyday basis, which hinders obtaining additional financial support. In fact, some directors have stated that too many centers have the potential to take trauma cases, which dilutes staff opportunities to train with significant numbers of cases.
Tel Aviv has a population of 3 million, yet has three Level I trauma centers. A potential solution to the lack of expert trauma surgeons would be to concentrate the trauma surgeons into two centers in Tel Aviv rather than three to further consolidate severe trauma patients and increase direct resources, including staff. Forcing a Level I unit to step down, however, is a controversial proposition. Nonetheless, concentration of expertise would not solve the problem of developing a new generation of expert trauma surgeons.
While Israel’s newly established trauma system significantly reduced inhospital patient mortality by 33 percent between 2000 and 2010, steps need to be taken to ensure that the system remains fully operational.1 Because the Israeli medical system is a hub for Western medicine in the Middle East, to deny optimal functioning of a trauma care system would be the equivalent of denying the best treatment possible for emergency cases to both Israelis and Palestinians.
With the recent escalation of terrorist attacks and rising tensions in Gulf states, a need for a trauma care system is critical for Israel and its neighbors. As relations with surrounding territories and countries hopefully improve, a well-established Israeli trauma system can further foster cooperation and sustained peace through collaborative training programs. Dr. Schrier’s training in the UM Ryder Trauma Center is a step in the right direction, but a national push to maintain the efficacy of Israel’s daily trauma system needs to be ensured.
A call for action
The authors are sharing these experiences as an example of the opportunity that academic programs have to help develop trauma systems globally. We believe our partnership with Israeli trauma centers can serve as a model for other academic institutions that are interested in helping other countries to develop sustainable trauma care systems. It is interesting to note that the UM tented hospital worked collaboratively the first days of the Haitian earthquake with the Israeli military rescue team. One of the graduated Israeli UM fellows, Guy Lin, MD, was in the Israeli military team that participated in the relief effort.
Based on UM Ryder Trauma Center’s more than 20 years of experience in offering a successful international trauma training program, the authors offer the following suggestions to academic medical centers interested in establishing a similar opportunity for trainees from other countries:
- Establish a sustainable funding source, either through salary support from the U.S. hospital or through the ministry of health for the country sending the trainee.
- Locate a champion at your institution who has a passionate interest in promoting better access to and quality of surgical care in a particular region or country and has the energy and connections needed to get the project started.
- Develop a sustained group of candidates once the program has been formed, as identified by surgeons in the country of origin.
- Promote the program through media outlets in the trainee’s country of origin.
UM continues to reach out to other countries to help them establish sustainable trauma systems. For example, UM has reached out to Palestine and has trained one fellow from Jordan and one from Saudi Arabia. At press time, the university also is in discussions with the United Arab Emirates to determine the feasibility of developing a trauma training partnership.
In November 2016, Marc De Moya, MD, FACS, director, surgical clerkship, Harvard Medical School, and medical director, trauma nurse practitioner program, Massachusetts General Hospital, Boston, organized a group of Harvard and UM physicians that traveled to Cuba to assist in the presentation of the first operative trauma training course and participate in the second Cuban Surgical Congress. Dr. De Moya is a graduate of the UM trauma and critical care fellowship program.
The trauma surgeons at UM Ryder Trauma Center look forward to continuing to support efforts to improve trauma surgery around the world, and we encourage other academic medical centers to explore similar opportunities.
The authors want to thank Hany Bahouth, MD; Miklosh Bala, MD; Gadi Shaked, MD; Dror Soffer, MD; and Michael Stein, MD, FACS, for sharing their views on the status of Israel’s trauma system. We also want to recognize Matthew Patton for his support in writing this article, as well as Nicholas Namias, MD, FACS; Louis Pizano, MD, FACS; Daniel Pust, MD; Carl Schulman, MD, FACS; Tanya Zakrison, MD, FACS; and the UM division of trauma and critical care, all of whom actively participated in the programs described in this article.
- Siman-Tov M, Radomislensy I, Peleg K. Reduction in trauma mortality in Israel during the last decade (2000-2010): The impact of changes in the trauma system. Injury. 2013;44(11):1448-1452.
- Soffer D, Klausner JM. Trauma system configurations in other countries: The Israeli model. Surg Clin North Am. 2012;92(4):1025-1040.
- Aharonson-Daniel L, Avitzour M, Giveon A, Peleg K. A decade to the Israel National Trauma Registry. IMAJ. 2007;9(5):347-351.
- Peleg K, Aharonson-Daniel L, Stein M, et al. Increased survival among severe trauma patients. Arch Surg. 2004;139(11):1231-1236.
- Goldman S, Siman-Tov M, Bahouth H, et al. The contribution of the Israel trauma system to the survival of road traffic casualties. Traffic Inj Prev. 2015;16(4):368-373.