Accidents can happen anywhere, at any time, every day.
But when the injury is traumatic and life-threatening, where and who do you seek help from?
This is where trauma surgeons – subspecialised general surgeons – come to the rescue.
In Malaysia, we only have six of them and they are all based in government hospitals.
A traumatic injury is one resulting from a blunt force or penetration.
Most such patients are victims of vehicle crashes, stabbings, industrial accidents or falls.
Traumatic injuries can affect our internal organs, including our bones, brain and other soft tissues of the body.
No area of the body is immune to trauma, but it can range from minor (e.g. hitting your finger with a hammer) to major (e.g. being hit by a car travelling at high speed or falling off a building).
The Health Ministry’s Trauma Surgery Services head Dr Rizal Imran Alwi says: “A cut in your hand and a broken leg are also injuries, but patients are not threatened with death.
“We will pick up the more severe patients who need urgent intervention.
“What we do is replicated in other developed countries, which mainly use the United States model for caring.”
He adds that the trauma surgeon’s function “is like a conductor of an orchestra”.
When a patient arrives at the emergency department, the emergency physician is the first to attend to him, with their role being to examine and stabilise his condition.
If the patient is polytraumatised, i.e. injured in multiple organs and requires surgery, the trauma alert system is activated.
Dr Rizal explains: “Everyone who is involved will come down (to the emergency department).
“Most of the time, the patient is dying because he is bleeding internally.
“External bleeding is less scary to us than internal bleeding because it can be dealt with.
“When there is internal bleeding, the patient has low blood pressure and may die silently.
“My job is to operate on him – anything from the neck downwards is fair game to us and we address the most pressing injury first.”
If the patient’s condition is critical enough to require resuscitation by the emergency physician, then he would require a “crash operation” as he is crashing, i.e. undergoing a sudden, adverse deterioration in their condition.
The patient will be immediately wheeled into the operation theatre, usually in less than an hour from the time of his arrival at the hospital.
Who operates first?
The trauma surgeon is often the person responsible for prioritising which injuries will be treated first and determining the order of the diagnostic and operative procedures needed.
Trauma involving neck, thoracic, abdominal, pelvis and vascular injuries come under their purview.
“I decide who goes next and does what,” explains Dr Rizal.
“After our team has done our part and we know the patient will not die, the intensivist or anaesthetist will then continue to resuscitate the patient in the intensive care unit (ICU).
“This is very hard to do – it’s like fish in an aquarium.
“You need to have everything for the patient so he can survive.
“The patient has to be strong enough to undergo the next operation.
“Then I’ll invite the other surgeons to do their part, e.g. neurosurgeon for brain injuries, orthopaedist for musculoskeletal injuries, maxillofacial surgeon for jaw/teeth injuries, etc.
“We also get support from the radiologist, transfusion physicians who provide us with blood, nurses, anaesthetists, radiologist, etc – it’s really a huge team.”
Obviously, the patient undergoes a lot of mental and emotional stress, so they are also given psychological support.
“So, from the time the patient arrives at the hospital to his discharge, he would have been looked after by 30-50 staff,” adds consultant trauma and general surgeon Dr Yuzaidi Mohamad.
When the patient is discharged from the ICU, he is moved to the normal ward and jointly cared for by different specialists, but the “conductor” still oversees everything.
Dr Rizal says: “After he goes home, we will see him again for follow-ups and put in place arrangements for rehabilitation, physiotherapy, speech therapy, social support, etc – all of which were not required in the beginning because the man was dying.”
It’s a long process to get the patient ready to function fully in society again.
“We bring them back from the brink of death to the point where they can go back to pre-incident function.
“Most of them are in the working age group and may end up in a different profession.
“Oncologists see their cancer patients suffering and dying; with us, if the patient dies, they die very early on, but if they can get back on their feet and be productive, that’s very rewarding for us,” he says.
A new field
Trauma surgery is still in its infancy in Malaysia.
Our first trauma centre was set up in Hospital Sultanah Aminah Johor Bahru (HSAJB) in 2011.
Both Dr Rizal and Dr Yuzaidi are based in HSAJB, which caters for the southern region, while the central region is headquartered at Hospital Tengku Ampuan Rahimah in Klang, Selangor.
The other four trauma surgeons are serving in the Klang Valley.
General surgeon Dr Muhamad Izwan Ismail is currently pursuing his fellowship, and upon completion, he will be the seventh qualified trauma surgeon in the country.
There are no trauma surgeons in the private sector as trauma surgery throughout the world is largely funded by governments.
“As for other areas in Malaysia, they do emulate us, but they don’t have fully-trained trauma surgeons yet – we are trying to produce them, but it takes time!” says Dr Rizal.
“We’re proud that out of the six, one is a female.
“Our training programme is three years and we have been doing this for a decade and a half.
“I was the first to get formally trained and went to Auckland, New Zealand, for my final year in 2010.
“General surgery has lots of divisions, e.g. colorectal surgery, upper gastrointestinal surgery, vascular surgery, etc, and we are a smaller subdivision – more of these twigs and branches have emerged in the world because there is a need for them.”
According to HSAJB’s 2018-2021 Trauma Surgery Registry report, blunt trauma makes up most of the cases, followed by road traffic accidents involving motorcyclists.
With an average of 18 persons killed in road accidents every day in Malaysia, road accidents constitute a serious public health challenge to the nation.
However, the highest death rate from road traffic accidents was recorded among pedestrians and those who fell from a height of more than 2m.
“The high impact of road traffic accidents to pedestrians is associated with higher speed and energy patterns.
“Our driving attitude is bad – we beat red lights, we don’t wear seatbelts, we don’t follow traffic rules – look at videos of delivery service drivers on social media and you’ll see what I mean!” says Dr Yuzaidi.
About a quarter of patients require admission to the ICU, and out of this number, 25% don’t make it.
The deaths are usually associated with the central nervous system and sepsis (the body’s extreme reaction to an infection).
Dr Izwan chips in: “Our overall mortality (death) for major traumas is 14.5%, and worldwide, it is less than 20%.
“Our numbers are good considering that we have been in operation for only 11 years.”
He adds: “Major traumas are defined using a scoring system based on anatomical regions.
“In HSAJB, we have more traumas from road traffic accidents compared to Klang, which sees more penetrative injuries, so the demographics are different.”
The boy is alive
The team shares one of its most memorable cases involving accident victim Muhammad Amirul Idham Surdin, 18, who was referred from Batu Pahat, Johor, to HSAJB last November (2021) due to his complex injuries.
The teenager had suffered multiple fractures and severe injuries to the duodenum, pancreas, kidneys and liver, and was bleeding in the brain.
Based on the New Injury Severity Score ‑ which helps to predict the chances of death and disability, among others ‑ Amirul had a score of 64/75 (the higher the score, the more severe the injuries).
“If you look at those injuries, he wouldn’t survive.
“But with a good coordinated trauma system, well-equipped trauma centre and dedicated staff, we managed to save this young boy so that he can continue to have a meaningful and happy life with his loved ones.
“He stayed with us (ICU and ward) for seven weeks, had six surgeries, was transfused at least 40 packs of blood products, and had rehabilitation, physiotherapy and social support before being discharged.
“Today, he can smile again and is en route to full recovery,” says a delighted Dr Rizal.
It’s cases like Amirul’s that brings joy to trauma surgeons.
Anaesthesiologist and intensivist Dr Mahazir Kassim says: “The advancement of trauma care has made it possible for people to survive and contribute to society – this is what we aim to do, and for that, we need the collaboration and coordination of multidisciplinary teams.
“We are still developing, but the outcomes are so much better than a decade ago when these patients would not have survived.”
If the team witnesses a road accident, would they stop and help?
Dr Rizal says, smiling: “Honestly, it would be scary to see a bad accident on the road – strangely, even I find it gory!
“But on the operation table at the hospital, it’s okay because I’m in a controlled environment with a support system in place.
“Would I stop and help someone who is bleeding on the road? Hmm...”
“Morally, we should!” interjects Dr Yuzaidi.
Back in the day, Dr Rizal notes, it was common to see good Samaritans or taxis come forward to help shuttle the injured to the hospital – and because they didn’t know how to properly carry the patient, a slight fracture would turn into a full fracture by the time the patient reached the hospital.
“Even as a doctor, I don’t know pre-medical care,” he admits.
Nowadays, it’s best to call an ambulance, which will come with paramedics trained in first aid and emergency response, and hope they arrive swiftly.
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