ATLS at 40: Distinguished past, bright future

The Advanced Trauma Life Support^® (ATLS^®) course is celebrating its 40th anniversary this year. As we honor the surgeons and physicians who pioneered the course and the health care professionals who continue to be a part of one of the American College of Surgeons’ (ACS) premier educational offerings, it is appropriate to reflect on where the course has been and where it is going in the future.

The evolution of ATLS

Since its inception in 1978, the ATLS program has reflected the evolving nature of trauma care and its associated educational principles. Early editions of ATLS focused on lectures, skills stations, initial assessments, and a multiple-choice test. The skills stations used a combination of mannequins and X-ray-based equipment, along with a surgical skills practicum in an animal lab.

Several skills stations came and went during early editions, including prehospital extrication, medical antishock trousers (also known as MAST), and application of Gardner-Wells tongs. As concerns about the use of experimental animals grew in many medical schools, several ATLS course sites moved from the use of animals to mannequins beginning with the Sixth Edition, in the year 2000. A focus group determined the attributes considered to be vital to ensure fidelity and parity with an animal model. Head-to-head testing found the new simulation model was comparable to the animal model.

In 1980, the course was adopted by the ACS Committee on Trauma (COT). The COT disseminated the course rapidly throughout the national regions. Shortly after that, the course was introduced in Canada and Mexico, becoming the gold standard for trauma care throughout the world. Today, many specialty boards require ATLS for certification, several hospitals require ATLS verification for physicians who provide care to trauma patients, and some states require ATLS for state licensure. ATLS training has become a requirement for health care professionals around the world, as trainees in various specialties, including general surgery, emergency medicine, orthopaedic surgery, anesthesia, and neurosurgery, are mandated to take ATLS before graduation or certification.

The ATLS course is revised and updated approximately every four years. The purpose of these revisions is to update content for both the faculty manual and skills stations. Course content changes were based on standard practice and expert opinion. Since the launch of the Eighth Edition, all updates to the ATLS manual have been evidence-based.*

Another significant change with the Eighth Edition was the involvement of the ATLS International family in course revisions. During the development of the Eighth Edition, the COT recognized that the ability to affect trauma care globally required local leadership, in addition to direction from North America. Region Chiefs were appointed to new international regions, and countries began to host collaborative meetings to support each other and grow ATLS programs regionally.

Major changes with the Ninth Edition

The Ninth Edition of the ATLS course brought even greater international involvement, and for the first time, courses taught outside of North America outnumbered those taught in North America (see Figure 1 below). This increased diversity has strengthened the ATLS program and has allowed it to examine some strongly held rules and policies to determine how well they fit with the present model of ATLS delivery.

One of the most vital organizational changes that happened in the development of the Ninth Edition of the ATLS course was the establishment of the Senior Educator Advisory Board (SEAB) and the formation of an active international coordinators group led by Lesley Dunstall, RN. The SEAB comprises two educators from each international region and two coordinators from the U.S. Raphael Bonvin, MD, PhD, was the first chair of the SEAB, and Debbie Paltridge, BAppSc(Phty), MHlthSc(Ed), is the current SEAB Chair.

Perhaps the most important shift that occurred with the Ninth Edition was the realization that trauma resources, care, and practices differ from location to location. As a result, the ATLS Subcommittee of the COT determined that Region Chiefs and Course Directors needed some flexibility to successfully teach a course that is relevant to both patients and providers in their countries. For instance, many countries do not use pericardiocentesis or diagnostic peritoneal lavage as a part of their standard trauma care, and so teaching these skills as a part of ATLS was unnecessary in these areas. However, in other areas of the world, these skills are considered lifesaving procedures. With the Ninth Edition, training in these skills sets became optional and could be included in the program at the discretion of the Course Director.

In addition, initial evaluation of the trauma patient can differ in both rural and urban hospitals throughout the world. Nuances regarding the role and medical specialty of physicians involved in trauma resuscitation vary by locale. One example is the placement of a chest tube. Mandates that only a general surgeon teach placement of a chest tube cannot be uniformly applied. This may sound unusual to trauma surgeons practicing in the U.S. Proficiency and skill of an instructor are far more critical than specialty. Thus, decisions about which health care professional should teach specific skills are now determined by Region Chiefs after a discussion at the ATLS Subcommittee level, rather than by the subcommittee itself.

The SEAB became a strong voice for using evidence-based learning techniques, which led to a push to increase the interactivity in the didactic aspect of the course. The Ninth Edition introduced a case scenario at the beginning of each interactive lecture and ended each lecture with a summary of the case. However, the instructor did not refer to the case during the lecture, and learning remained dependent on the lecturer delivering the content.

The Ninth Edition in 2012 also saw the introduction of the MyATLS app, the first foray of ATLS into an electronic learning platform, which includes supplemental course materials. George Brighton, MD, from the U.K., and Wesam Abuznadah, MD, MB, ChB, FACS, FRCSC, a SEAB educator from Saudi Arabia, led this effort. The MyATLS app increased the reach of ATLS content far beyond the 86 countries that have formal ATLS programs, as it has been downloaded by users in 181 countries, allowing providers access to lifesaving knowledge and skills videos. The MyATLS app also demonstrated the powerful potential of a mobile electronic platform to deliver ATLS content as a supplement to a traditional ATLS course. When the time arrived for the 10th Edition revision, ATLS was again well prepared to take the next steps to increase the interactive nature of the course, as well as to continue incorporating evidence-informed content.

Figure 1. ATLS programs in place as of December 2017

ATLS today

As of the end of 2017, approximately 1,046,788 physicians and advanced practice health care professionals have been trained in ATLS in 86 countries. International students represent more than half of the students trained annually. Not surprisingly, as ATLS’ global reach has matured, the rate of addition of new countries to the ATLS family has diminished. Importantly, the enthusiasm for the knowledge provided in the courses remains strong. ATLS is the foundation of efforts to improve and standardize injury care nationally and internationally.

The ATLS framework has led to multiple offshoot programs. Prehospital Trauma Life Support (PHTLS) and Advanced Trauma Care for Nurses (ATCN) continue to promulgate, often in parallel with ATLS. The value of coordinated and integrated prehospital and nursing care with the care delivered by the physician or advanced practice health care professional cannot be overemphasized. Both the PHTLS and the ATCN programs are in the final stages of revision, and course developers are working closely with ATLS to ensure the consistency of course content. The ATLS program has provided an organizational basis for trauma system development nationally and internationally. Lifelong collaborative relationships have developed through the creation of, first, national regions, followed by international regions.

ATLS has, from its inception, endeavored to use the most effective educational principles to ensure the credibility of the course. The medical educator has been an integral part of the ATLS program, and the establishment of the SEAB with the ATLS Ninth Edition was a critical factor in ensuring that continued involvement. The talented and erudite SEAB members have taken on an increasing role in the revision process in addition to the role in course promulgation. One of the qualities of ATLS that has allowed it to endure these 40 years has been the program’s dedication to policy, quality, and standardization. As ATLS embraces new technology to deliver content, the course developers have been mindful of the elements that have led to the program’s success. Providing one safe way to perform the early resuscitation of the injured patient while creating an educational atmosphere of trust and family is the guiding principle of ATLS training. The provision of alternative formats such as a hybrid course model must not lead to deviation from standardization or quality.

10th Edition launches this year

The 10th Edition of ATLS, which launches this spring, includes the most significant changes in the presentation of the course since its inception. The rollout of the 10th Edition includes the option to provide a portion of the content of the course online. Given the success of the MyATLS app, the mobile presentation of some course materials follows as a logical extension. The mobile option, mATLS, will allow students to access course content previously presented as standardized interactive discussions on desktop or laptop computers, tablets, or smartphones. Learners gain the flexibility to access course content at their convenience using the device of their choosing.

Content presentation remains standardized in the mobile format. Intermittent assessments using multiple-choice and fill-in-the-blank questions along with “voice of experience” videos have been included to ensure interactivity. This hybrid format places responsibility for preparation squarely on the student. Adult learners are known to be autonomous, self-directed, and goal-oriented, and the changes in the presentation of the 10th Edition support this learning model.

The format of the traditional 10th Edition is changing as well. Interactive group discussion (IGD) replaces the in-person interactive lecture. The IGD begins with a patient scenario that unfolds to support the learning content discussed. Nonetheless, the highlight of the course continues to be the in-person interaction between the students and instructors. During this interaction, novice providers find mentorship and experienced providers develop lifelong collegial relationships. This affective domain of learning has added to the appeal of the course and is considered by course educators and instructors to be a valued aspect of ATLS training. When the hybrid format is chosen, students must continue to report in person for a day-and-a-half of skills and testing.

ATLS recognizes the fact that teams frequently deliver injury care. Because providers, even in low-resource or rural settings, are able to create teams to care for the injured, each chapter now contains content about team functions as they relate to the individual topics. Additionally, a new skills station highlights basic concepts of team communication. Lastly, an optional chapter on Trauma Team and Resource Management has been added.

The skills stations continue to be a highlight of the course. The mandated low student-to-faculty ratio facilitates the use of the most successful method to teach new psychomotor skills. The skills stations, like the IGDs, will feature an unfolding patient scenario. When the skill or intervention is required based on the evolution of the scenario, the student performs the skill. Though the overall skills taught remain mostly unchanged, with the addition of a few new skills, the skill stations have been consolidated to better reflect the ATLS model (see Table 1). Bleeding control techniques, such as wound packing and application of a combat tourniquet, are new to this edition.

Table 1. Differences between ATLS Ninth and 10th Edition Skills Stations

Skills are frequently taught using simulators. During the initial transition to simulators from live animals, a high value was placed on the fidelity of the model. As experience with simulation has increased, it has been confirmed that low-fidelity simulation can be adequate for teaching surgical skills.^† Partial task trainers are increasingly available for lower cost and often produced internationally, offering an attractive alternative to standard simulators. With central oversight, some course sites have creatively produced innovative “homemade” options at even lower cost for teaching ATLS skills (see photos below).

Stop the Bleed^® is a course developed through collaboration among multiple stakeholders, including the ACS, to train the lay public to recognize and control life-threatening hemorrhage. To support the College’s effort to foster mass public training, ATLS course directors have the option of adding a short module to the course that enables students to become Stop the Bleed instructors. After completing the course, these individuals are then empowered to hold classes in their own communities.

The ATLS 10th Edition course rollout will continue throughout 2018, with the expectation that all courses will be using the newest version in 2019. It is expected that the hybrid mATLS courses will be in widespread use soon after that.

Looking forward

As ATLS enters its fifth decade, it remains as relevant as ever. Although trauma care has evolved significantly over the last 40 years, as illustrated, for example, by changes in our understanding of shock and coagulopathy and the use of damage control procedures and balanced resuscitation, the basic tenets of ATLS continue to provide a framework for practitioners to safely care for the critically injured patient. It is a testament to the wisdom of the initial designers of the course that over multiple iterations, accompanied by both substance and stylistic changes, the core principles of ATLS and its approach have stood the test of time. Specific details may have altered, but the guiding philosophy of promptly identifying and addressing immediate life threats, performing an efficient secondary survey when possible, arranging for access to definitive care, and using standardized communication will continue to serve providers well.

Along with advances in understanding, enormous leaps in technological capabilities have occurred. The development of the ATLS app and the new mATLS course present opportunities for education and outreach that the founders could not have predicted when the course was first introduced. Making use of the technology that is advancing telemedicine/telehealth, ATLS content may very well be delivered to even more providers in even the most remote locations in the future. Courses in the future may involve not only interactive discussions, but possibly skills instruction and initial assessment testing using this technology.

And as technology facilitates the reach of the course, it is likely to become more personalized. Blogs and listservs currently exist, but other technologies may make it possible to easily update relevant ATLS content between editions. ATLS experts may more easily act as “remote mentors” to newer sites, resuscitation teams, and individual practitioners.

As ATLS and trauma care have advanced, some areas of concern have become manifest that will likely need to be addressed in future editions. The trauma community has been actively involved in injury prevention for some time, and prevention must become a more integral part of ATLS in the future. As more people are able to survive catastrophic injuries, issues around trauma recovery, including post-traumatic stress disorder and post-intensive care syndrome, will also need to be considered.

Helping practitioners become effective advocates for policy change and quality improvement are other areas in which ATLS may be able to provide relevant educational assistance to providers in the future. These concepts dovetail with the stated goals and three pillars of the COT: Quality, Education, and Advocacy. ATLS, as the COT’s prototype educational offering, is well-positioned to advance those objectives.

*Kortbeek JB, Al Turki SA, Ali J, et al. Advanced Trauma Life Support, 8th Edition, the evidence for change. J Trauma. 2008;64(6):1638-1650.

^†Cosman P, Hemli JM, Ellis Am, Hugh TJ. Learning the surgical craft: A review of skills training options. ANZ J Surg. 2007;77(10):838-845.