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 …