Looking forward – August 2013

David B. Hoyt, MD, FACS

This month’s Centennial reprint from a past issue of the Bulletin, centers on the roots of one of the American College of Surgeons’ (ACS) most successful educational programs—the Advanced Trauma Life Support® (ATLS®) course. Since the ACS began presenting the course more than 30 years ago, more than 1 million physicians in more than 60 nations have trained in the lifesaving techniques presented in this program.

Modest beginnings

ATLS has humble roots. The pilot course was presented in Auburn, NE, in 1978 at the request of several physicians and nurses in nearby Lincoln. This appeal came on the heels of an airplane crash in a rural Nebraska cornfield in February 1976. Piloting the plane was J.K. Styner, MD, FACS, an orthopaedic surgeon. Dr. Styner sustained serious injuries, three of his children sustained critical injuries, and one child sustained minor injuries. His wife died on impact. Dr. Styner maintained that the care he and his family received was inadequate, stating, “When I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system, and the system has to be changed.”*

Soon after the pilot course was presented in Auburn, Paul E. “Skip” Collicott, MD, FACS, Past-Director of the ACS Division of Member Services and a recipient of the College’s Distinguished Service Award, introduced the concept of the ATLS program to the ACS Committee on Trauma (COT) at their 1979 annual meeting in Houston, TX. The COT enthusiastically endorsed the proposal and called upon its Region Chiefs to meet in Lincoln for an introduction to the course.

With that, in January 1980, the College initiated the promulgation of ATLS as an educational program to teach health care professionals about the initial care of injured patients. Later that year, the course was presented in Denver, CO; Dallas, TX; San Diego, CA; Washington, DC; Philadelphia, PA; Newark, NJ; Opelika, AL; and Milwaukee, WI. The course spread to Canada in 1981 and was introduced to the international community beginning with Latin America in 1986.

Fellows’ perspectives

As we reflect on the College’s litany of efforts to promote quality patient care, many Fellows would agree that the ATLS course ranks high on that list with respect to success—both nationally and internationally. I recently contacted several prominent trauma surgeons who have been involved in presenting and fostering the ATLS course and asked them to share their experiences and insights. Here’s what they had to say:

“Starting in 1974–1975 the COT took on a number of projects to improve trauma care and outcome in trauma patients. The ones that were very successful included ATLS, verification, and the National Trauma Data Bank®, to name a few,” said Donald Trunkey, MD, FACS, Past-Chair of the COT. “ATLS has been a clear winner. First, it allows surgeons to develop their own criteria, which is very important to get better outcomes. In many centers, ATLS can salvage up to 30 percent of major injuries where cardiac function has ceased. Clearly, Dr. Styner, who founded this resuscitation model after he had a plane accident and his wife was killed and the children very severely injured, deserves kudos, as does Skip Collicott for bringing it to the COT.”

John A. Weigelt, MD, FACS, Past-Chair of the COT, said, “I remember my first ATLS course vividly. Skip Collicott and other Nebraska surgeons were present for the first instructor course in Dallas, TX. I was a senior resident and was impressed with the dedication of the faculty and especially the educator, which was John George [MD, FACS],” he said.

“I have never seen a more dedicated group of doctors from around the world come to consensus on difficult issues,” Dr. Weigelt said of his experience in working with other surgeons and physicians to develop three editions of the ATLS manual. “All viewpoints were allowed and vetted until true agreement was reached.  Such cooperation simply strengthens the ATLS content and truly makes it a common language for the care of the injured patient.

“My other fond memory of ATLS is when we took the first course to Hong Kong and Beijing,” Dr. Weigelt added. “In Beijing we presented parts of the course using a translator, which was challenging.  It was terrific to watch our audience attempt to capture every word and concept that we presented.  I am not sure I have ever had as attentive an audience for our ATLS principles.”

The international experience is one that resonates particularly strongly with other ATLS leaders as well. “As President, I’m finding in country after country ATLS is our most successful outreach program and has won us friends all over the world,” said ACS President and Past-Chair of the COT A. Brent Eastman, MD, FACS. He attributes some the course’s successful promulgation internationally to the efforts of former ATLS Committee Chair Brent Krantz, MD, FACS, whom Dr. Eastman appointed. “Brent Krantz did a spectacular job always with his strong rural background and sense of humor,” he said.

“To further promote the program internationally, I was involved in a seminal meeting with Stephen Deane [MB, BS, FACS] and Peter Danne [MB, BS, FACS, FRACS] from Australia when I was Chair of the COT,” Dr. Eastman said. “The Royal Australasian College of Surgeons wanted to adopt ATLS but felt there needed to be some flexibility to make it relevant to their needs. The situation had reached a critical impasse. However, in an evening meeting in a lounge in San Antonio, TX, Drs. Deane, Danne, and I managed to work out an agreement that moved things forward. This was an important bit of international diplomacy, because the Royal Australasian College of Surgeons has gone on to have one of the strongest ATLS—they call it Early Management of Severe Trauma, EMST—programs in the world.”

Also addressing ATLS’ effect on improving trauma care internationally, Past ATLS Committee Chair John B. Kortbeek, MD, FACS, said, “I witnessed firsthand the difference ATLS made in my home province of Alberta, Canada. Referring centers as well as our in-house trauma teams now provide standardized, safe, high-quality care. The program has evolved from its humble beginnings to a global partnership supported by experts across cultures and disciplines,” added Dr. Kortbeek, who received the ATLS Meritorious Service Award in 2012 and is presently involved in international promulgation of the program.

“It’s hard to put into words what the opportunity to lead ATLS has meant to me,” said current ATLS Committee Chair Karen Brasel, MD, FACS. “To see people who might agree on little else put aside personal and political differences to invest countless hours (and in many cases, their own money and other resources) to improve the program, and to bring trauma education to their own countries speaks to the value of the program and to what can be accomplished when the focus is truly on the patient and doing the right thing,” she noted.

“The recent adoption of ATLS by countries in the Middle East, where there are both political and safety hurdles, is truly a triumph of the regional structure and international ATLS family in addition to the triumph of right over politics,” Dr. Brasel added.

A program for the next century

Now in its ninth edition, ATLS has become the gold standard in care for injured patients throughout the world. To ensure that health care professionals have easier access to the latest information and techniques in trauma care, the newest edition of the ATLS Student Course Manual, released at the 2012 Clinical Congress, has a companion app. The mobile app is available for download at MyATLS.com and is being continually updated for use in the field.

The College couldn’t be more proud of the success that ATLS has experienced. As ACS Past-President L. D. Britt, MD, MPH, DSc(Hon), FACS, FCCM, FRCSEng(Hon), FRCSEd(Hon), FWACS(Hon), FRCSI(Hon), FCS(SA)(Hon), said, “There has been no program that has been as effective as ATLS in saving lives and decreasing the morbidity of injuries. It is one of the greatest medical innovations—worldwide—in the last 75 years!”

The College looks forward to building on this achievement as we move into the next 100 years.

*Fildes J. History of the ATLS® Program. Available at: www.facs.org/trauma/atls/history.html. Accessed June 28, 2013.
†Collicott PE. ATLS® celebrates 25th anniversary. Bull Am Coll Surg. 2005;90(5)18-21.

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