ATLS: Archaic Trauma Life Support?

No one could have imagined that when a light aircraft crashed in rural Nebraska in 1976, the nature of global trauma management would be forever altered. James Styner, an orthopaedic surgeon, was piloting the plane in question and the accident resulted in the death of his wife and serious injuries to himself and his four children. The standard of care that he and his family received in the local hospital in the aftermath of the crash so horrified Styner that he decided to establish a new system for the management of major trauma. Lincoln Hospital, Nebraska, had already developed the foundations of the Advanced Cardiac Life Support (ACLS) course and utilising the same pedagogical principles, a course was designed to ‘educate rural physicians in a systemic way to treat trauma’ [1]. A pilot course was run in Nebraska in 1978, and by 1980, the Advanced Trauma Life Support (ATLS) course had been adopted by the American College of Surgeons and was taught throughout the USA, reaching the UK in 1988. Courses are now run globally, with over one million candidates trained in 60 countries [2]. There is no doubt that the ATLS course principles added some much needed structure to the initial management of multiply injured patients. Before the well-known ‘ABCDE’ stepwise approach, trauma patients had been managed similarly to general medical patients, with a focus on history and examination before any intervention. This was particularly important in trauma management before the advent of major trauma centres (MTCs), with immediate management provided in multiple different regional hospitals. As a result, care was often provided by junior doctors from a variety of specialties, with varying levels of relevant experience and only infrequently working together as a team. ATLS brought a common language to the management of trauma and highlighted the importance of immediately dealing with life-threatening conditions, as part of a standardised, systematic protocol. The ATLS manual is now in its ninth edition [3], but over the three decades since its incarnation, trauma management within the UK has changed radically, primarily as a result of the establishment of MTCs [4]. The UK now has a network of hospitals providing expert and predominately consultant-led trauma care on a 24-hour basis. The provision of advanced pre-hospital care is being expanded [5] and the lessons learnt by the military medical services during recent conflicts are being translated into civilian practice [6–8]. In the context of this rapid and continual evolution of trauma care, how relevant is the ATLS course in the 21st century management of major trauma? Despite the global acceptance that the ATLS management principles appear to represent a gold standard in trauma management, there are few data that suggest ATLS training has meaningfully reduced trauma-related morbidity and mortality in the developed world. A Cochrane meta-analysis [9] examined 2007 citations in order to assess the effect of ATLS training. The authors were unable to identify any randomised control trial with morbidity or mortality as an outcome measure, with the only five relevant studies focusing on acquisition of knowledge and retention of skills. As a result, they concluded that there was no clear evidence of benefit for ATLS training and that future research should be in the form of a sequential, before–after design in a healthcare system where ATLS is not currently in use. A review by the same group on ATLS training for paramedics came to an identical conclusion [10]. Previous work has focused on the impact of ATLS in developing countries [11–14], countries without formal trauma management systems [15, 16], or institutions that admit low numbers of trauma cases [17– 19]. In addition, the medical participants recruited in such studies are