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ATLS is at a crossroads in its development
The family tragedy in 1976 gave birth to the trauma legend known as ATLS. In that year a plane piloted by the orthopaedic surgeon J Styner crashed in Nebraska. His wife was killed and four children seriously injured. Unfortunately for Dr Styner he found that the subsequent care received in the local hospital was inferior to what he was able to provide for 10 hours at the scene of the accident. In the ensuing inquiry the need to train clinicians in trauma care became evident.1
Using the educational structure of the recently developed ACLS programme, the first ATLS course was run in Nebraska in 1978. The following year it was taken up by the American College of Surgeons Committee on Trauma (ACS COT) and rapidly spread throughout the North, Central, and South America. Today ATLS is taught in over 42 countries and around half a million clinicians have completed the course (I Hughes, personal communication). In the UK alone over 13 000 providers and 3000 instructors have been trained since its arrival in 1988 (S Dilgert, personnel communication).
As Nolan says in his article, ATLS originally represented a state of the art training course on the care of major trauma.2 Its new and refreshing educational format made it accessible to all clinicians dealing with trauma in the resuscitation room. The reason for this was that it incorporated clear clinical principles that underpin the course. These have not changed in 28 years:
Trauma is a surgical disease
Treat the greatest threat first
Lack of history should not prevent assessment starting
Lack of a precise diagnosis should not prevent treatment starting
The course teaches one safe system
These principles became translated into the now famous structured approach to trauma care. With even medical students being familiar with this system, it is easy to forget how revolutionary these thoughts were in 1976. Older readers will empathise with McKeown’s comments regarding the state of trauma care in the UK in 1988 when ATLS first arrived.3
Integral to the success of the ATLS course was the educational principles on which it was based. Out went the formal lecture; in came the intimate, almost personal tuition. The 2.5 day course is intense but supportive allowing candidates to learn from instructors in a variety of ways.4 The pace of the course builds up, crescendo-like, to the point when the candidates carry out their own simulated resuscitation. All other life support courses, and indeed significant parts of undergraduate and postgraduate training, have subsequently copied these educational points.
The final element in the success of ATLS is its quality control system. From its inception it aimed to provide a system of care that was safe, effective, and able to be practised in all trauma receiving hospitals. Through the offices of the ACS COT the manual and course was reviewed every four years. They also only issued providers and instructors with certification valid for the same length of time—again to encourage clinicians to remain up to date. With strict use of copyright and control of dissemination, the character of the course has been maintained over 26 years, six editions, and transfer to 42 countries. ATLS remains an internationally recognised standard of care and is an icon for all other life support courses and educational formats.
With such glowing praise it may seem churlish to criticise it. There are however some significant problems that require serious consideration. From its origin it is easy to understand the ACS COT view of “Trauma being a surgical disease”. As a consequence ATLS can only be exported to a surgically approved centre (such as the Royal College of Surgeons) and a surgeon must direct all courses. Unfortunately these rules do not reflect reality. The TARN databases since 1990 show that 65.4% of the cases required surgery of which 24.5% needed it within eight hours (M Woodford, personnel communication). Most of these cases were orthopaedic procedures. As Nolan states the trauma patients are managed by a team of people representing a range of specialties—most notably emergency medicine, anaesthesia, and orthopaedics. This heterogeneity is reflected in the course participants—32.7% come from anaesthesia, 24.6% from emergency medicine, and 16.8% from orthopaedics (S Dilgert, personnel communication). It is therefore interesting to note that up to the latest edition there were no emergency medicine or anaesthetists acknowledged as contributors to the course manual.
Nolan and McKeown list further inconsistencies between the course and how trauma care is practised in the UK and other countries. Important areas of controversy, such as airway management, may simply reflect US practice and the lack of non-surgical input into the course preparation. Davis also reviews the educational principles underpinning ATLS and how UK instructors have interpreted these differently.4 The interactive approach with a community of practice ensured by the instructors being there for the whole course are not typical of US run ATLS courses.
As ATLS courses are not cheap to set up, run, or attend, their cost effectiveness has been questioned. Of all the life support courses, ATLS has probably been subjected to the most appraisals. They are known to increase knowledge and skills (at least temporarily), confidence, and lead to a change in practice.1 In contrast it has never been shown that the courses increase patient survival or reduces disability. As ATLS addresses only one aspect of a spectrum of care this is not surprising.
All these issues would be tolerable if it were not for the perceived rigidity in the ATLS organisation. The time delay in bringing about changes and the problems in trying to incorporate non-US practice has led to discontent even within ATLS supportive groups. The latest edition being launched this month in the UK three years late only increases this disquiet. In view of these problems, the desire for evidence based medicine, and the financial restrictions on postgraduate education, it is understandable that people are asking would it be better to run our own trauma course.
ATLS development is at an important crossroad in the UK and, possibly, in the world in general. There are three main options. Firstly, no changes could be made to the organisation. The current problems could be put down to a passing phase and the previous good track record used to show that there is no need to change a winning formula. The risk with this option is that people do not think the “formula is winning”. As a result the decline in enthusiasm for the course would continue and limit further spread in the UK and to other countries.
The next option is to develop a completely new course with an entirely UK (or European) group of instructors and educationalists with its own production, distribution, and quality control administration. Such an answer would have the advantages of relevance and cost control. There would be the problems of increase in variation with other countries, lack of international recognition, and problems of maintenance. In addition it needs to be appreciated that while details of treatment might change, it is unlikely that the basic system used for ATLS could be improved; the phrase, “re-inventing the wheel” comes to mind.
Before accepting this option the driving force behind the individuals and groups wishing to see a separate UK or European course also need to be considered. Many protagonists honestly believe the disadvantages of staying in the ATLS family outweigh its advantages. A minority are motivated by more transient emotions such as feeling excluded, xenophobia, and possibly even jealousy. It is important to know what is driving people because the costs and time commitment required to develop this type of course are huge, even for the UK. If one considers a European based course then the problems increase further. Nevertheless it is possible and there are structures and personnel who can do it. The question is, are advocates for this option motivated enough to keep it going over 26 years and six editions?
The final option, as described by McKeown, is to increase the involvement of international groups. In so doing issues such as core content (for all) and peripheral (for local needs) could be addressed along with the thorny issue of cost versus resources. This solution is likely to generate enthusiasm, and passion because of its local relevance while being part of an international family. However, these advantages would need to be balanced against reduced central control, finances, increased variation, reduced quality control, and an increase in organisational complexity.
In summary, from its tragic origin ATLS has become an icon in medical education. However, its quality control system and administration has led to rigidity and a perceived lack of interest in non-US ways of managing trauma. There is no doubt that ATLS is at a crossroads in its development. To do nothing runs the risk of a schism developing. Alternatively it could adapt to become a truly international course. Either option will require trauma enthusiasts wishing to develop a more effective course for patients rather than as a reaction to a current set of problems.
ATLS is at a crossroads in its development
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