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The strong ATLS infrastructure can provide a basis for the production of a truly international trauma course
I first heard of ATLS when I was a very junior consultant in anaesthesia and ICU. I had attended a meeting at which a (quite famous) intensivist had said that all major trauma patients should be anaesthetised, paralysed, intubated, have bilateral chest drains inserted, and undergo diagnostic peritoneal lavage. He claimed that this (in my view, dangerous) philosophy was taught at ATLS courses. These courses had only just been introduced to the UK, and were being supported by the Royal College of Surgeons of England.
I therefore sought out an ATLS course to attend as a confirmed sceptic. It is a tribute to the teaching and quality of that course (Guildford, since you ask) that I became convinced that ATLS, although “American” in flavour, had much to offer UK trauma care at that time. I also learnt that much of what is said in criticism of ATLS is said by people who know very little about it.
It is difficult to believe how disorganised much of the trauma care in the UK was at that time. Many small hospitals not far removed from the “community hospital” of the triage scenarios received seriously ill trauma victims with only a senior house officer in the casualty department, and no other post-registration doctor on site. Early resuscitation was haphazard and poorly coordinated.
ATLS courses, instructors, and providers began to be part of a change process, which improved the system considerably throughout the UK. This was not solely attributable to ATLS, but the introduction of these courses to areas provided a focus for interested local parties, and acted as a catalyst to encourage change and reorganisation. Alliances were forged for local clinical teams, and nationally between multiple specialties.
I feel we must also acknowledge the enormous contribution that ATLS has made to encouraging and developing the teaching of medicine and practical procedures. There were, to be sure, courses in education, but few offered the common sense and practicalities of an ATLS instructor course.
So ATLS became an integral part of UK medical training either through formalised and official courses, or in practical in-service teaching. The UK had, after an initial flirtation with a “fundamentalist” reading of the manual, generally accepted that the core system provided a logical guide to initial management of the trauma victim. The American focus of the manual even began to take over—although I have not been referred a “diaphoretic” patient, they have certainly been “obtunded” or “combative”. This was seen as an amusing quirk, whcih could, and would, be solved in future editions.
The American College of Surgeons (ACS) has been, however, slow to change much of the course content or materials. In many cases, that delay has been supported by subsequent research and clinical protocols—those who have loudly criticised the use of crystalloid solutions are less vociferous since the publication of the SAFE study from Australia, for example. Other changes did not seem to accept good evidence, which was passed to the ACS by members of the UK ATLS National Committee, which I was a member of for some years. For anaesthetists, the description of drug assisted intubation for adults and children remained contentious, and the lack of appreciation of the role of emergency physicians and anaesthetists in the management of trauma in the UK and other countries was frustrating.
The manual has been, where possible, evidence based, and therefore has rarely promoted new and unproven techniques. Some feel, however, that this has made the manual less up to date. Techniques that would bear introduction or discussion could include the use of restricted volume resuscitation as a part of care including early access to surgery, or damage control surgery and critical care involvement. These are certainly topics that are raised at UK courses, and their lack tends to detract from the title advanced trauma life support.
Do these concerns mean that we should leave the “ATLS family” and start a UK course? Like all those who threaten to leave the family home, perhaps we need to think clearly before acting.
ATLS still provides a strong, simple message, which is easily taught to all grades and disciplines. The UK and allied countries teach it in a way that emphasises the importance of its underlying principles, and tolerate and explain differences in US practice that are in the manual. The fundamental message is, I believe, still clear and relevant to our practice.
It would not be difficult to find a group of enthusiastic UK doctors with experience, and a real interest, in improving trauma care and teaching others to produce a manual more accurately aimed at UK practice. What would be difficult would be getting them to agree absolutely on a single approach, phrasing that unambiguously, and producing copy to a deadline with appropriate references. They would also have to agree to revise it all again to ensure the next edition of the manual was up to date.
The UK is not the centre of trauma care in the world. There are other groups of clinicians who also see similar patterns of trauma to the UK, with strong clinical and research links to ourselves—both in Europe and Australasia. Any new teaching development should logically involve them in course development and expansion. We have much to learn from them—for example, I feel the best organised ATLS course system in the world is probably the Danish one.
These groups of Europeans and Australasians currently are united in their wish to give constructive feedback to the ACS, with the aim of continuing to improve a course that has transformed trauma care worldwide. In many ways the course, which originated in the continental United States, has grown to provide a true international language of trauma care. However, that course desperately needs to more accurately reflect the variation in trauma patterns and systems existing outwith the USA.
I personally believe that it can do so, without diluting the overall message, if the ACS are willing to listen. I feel that they are beginning to appreciate that the overall teaching, course organisation, and quality control in the UK, Europe, and Australasia exceeds that of many of their courses. Guest ATLS instructors teaching on US courses are often disappointed at the quality of teaching and lack of coherent faculty involvement.
Perhaps the ACS should reflect on the similarities between the origins of their own great country—when the “colonials” expressed their concerns that a central and distant organising authority failed to appreciate the particular problems of local issues—and the expansion of a course that truly needs to be less American, and more international. A Boston Tea Party with consignment of course manuals to the bottom of the Atlantic should be avoided at all costs. We should never fail to appreciate, however, the vision and enormous efforts of the originators of ATLS in the US, and the evangelical zeal that has made it the worldwide success that it undoubtedly is.
I conclude that, if the ACS were to show a serious willingness to take constructive feedback from European, Australasian, and other medical systems, a truly international trauma course could be produced that would build on the strong ATLS infrastructure present in many countries. To fail to do so risks destruction of the current international coalition of like minded trauma practitioners.