Bringing ATLS to an international audience: Background and a Region Chief’s experience

In 1986, Trinidad and Tobago, a dual-island Caribbean nation and part of American College of Surgeons (ACS) Committee on Trauma (COT) Region 14, was the first country outside of North America to successfully host an Advanced Trauma Life Support^® (ATLS^®) course. On the heels of this milestone, several countries hosted ATLS courses in the early 1990s, including the following: Israel in 1990 (Region 15), Saudi Arabia in 1991 (now part of Region 17), and Singapore in 1992 (Region 16). Over the course of the next two decades, many other countries also began hosting ATLS programs. The promulgation process required a site visit conducted by a member of the ATLS Subcommittee of the COT, training of prospective instructors in North America, and the inaugural in-country course led by members of the ATLS Subcommittee.

With the growing interest in ATLS outside of North America, the COT recognized that to have a more significant impact on global trauma, international regional leadership was necessary. Latin America was the first to build the structure of regions with oversight provided by Ricardo Sonneborn, MD, FACS, from 1987 to 1995. In 2007, the COT officially identified new regions of interest, and the first Region Chiefs were appointed. Renato Poggetti, MD, FACS; Claus Falck-Larsen, MD; and Michael Hollands, MB, BS, FACS, served as the Region Chiefs of Regions 14, 15, and 16, respectively. At the time, Region 14 included Latin American countries and the Caribbean; Region 15 comprised Europe, the Middle East, and Africa; and Region 16 was composed of Australia, Asia, and North Africa. In 2011, Saud Al Turki, MB, BS, FACS, ODTS, FRCS, a co-author of this article, became the first Region Chief of the newly established Region 17, which serves the Middle East and North Africa.

These leaders revolutionized ATLS, allowing course promulgations to be conducted using the expertise and resources available within the region. The International Region Chiefs became contributors to the continued development of the ATLS course as authors and editors. Most importantly, they set the stage for addressing trauma as a globally significant disease—not only through their work with ATLS, but with leadership in the key areas of prevention, systems enhancement, and advocacy efforts in their regions. This leadership continues with the following Region Chiefs: Maria Fernanda Jimenez, MD, FACS, Region 14; Andrew Baker, MD, FACS, Region 15; Gilberto Leung, MD, FACS, Region 16; and George Abi-Saad, MD, FACS, Region 17.

As trauma care has advanced in North America and beyond, it is sometimes easy to forget the circumstances that led to the development of the ATLS course. What follows is the experience of Dr. Al Turki.

ATLS: A life changer

ATLS, for me, was a divine experience, one that changed my life and career.

I have been fortunate to accomplish a great deal as a father and a surgeon, but on reflection, one of my most meaningful achievements is my involvement in ATLS. Teaching ATLS not only in my beloved country of Saudi Arabia, which has 36 centers, but also expanding its reach through promulgation to more than 15 countries in our region has been immensely satisfying.

The friendships made along the journey and the places I visited were not all expected, but each episode has been a blessing that was made possible by the ATLS program, which educates health care providers in lifesaving care techniques.

Saudi Arabia was the first country in Region 17 to offer the ATLS program. My involvement in the inaugural course was genuinely coincidental. I went to the hospital to greet my colleagues, and the hospital administrator requested that my chairman add me to the course participants. It was not my choice, and I had no clue about the program, but within one year, I was appointed to be the ATLS course director and the chair of the program.

Participation in this program is contagious. Once you are exposed to the ATLS program, you most likely will develop sincere admiration for, and camaraderie with, your program colleagues, and you will be infused with a seemingly endless supply of energy. The ATLS family goes beyond what we know in terms of a family united by blood; it’s a family born of a cause.

Disseminating the course in a place of unrest where it’s hugely needed—namely the Middle East and North Africa—is an eye-opening experience that provides more insight regarding the needs met by the ATLS program. I have learned during trips to Region 17 countries to be a collaborator, a politician, a scout for champions, and a motivator of teammates. In my role, I promote the ATLS program to the right people, and then the program and all of its participants take care of the rest.

Region 17 is established

One of those ATLS program champions, Subash Gautam, MD, FACS, and I recognized that including Middle Eastern countries within the European region (15) was neither logical nor practical due to distance and cultural differences. We petitioned to establish a new region within this area, and with the help of our colleagues at the ACS headquarters in Chicago, IL, we were granted an independent region, Region 17. It took a moment to grasp the significance of this development, one that has led to both real excitement and the reality of a daunting challenge.

I was fortunate to be the first Chief of Region 17, but I was even luckier to collaborate with the leaders and champions who helped us achieve our mission.

Our region is not homogeneous by any standards, despite a common language (Arabic). The various countries within this region have significantly different customs and beliefs, and our history is complicated by political differences.

Expansion throughout Arabic countries

Our mission was further challenged by the Arab Spring, also known as the Arab revolutions, which commenced in 2010, leaving Syria in a civil war during which it lost more than a half million people and more than half of the population was left without shelter.*

The thought of going to Baghdad, or, in fact, any place in Iraq during this particular time of unrest, was like walking closer and closer to the edge of a cliff to see a magnificent view but with the possibility of losing your footing. With the help of Anees Nile, MD, FACS, professor, Nahrain University and Chair of ATLS in Iraq, we hosted a course of the highest quality under these challenging circumstances.

Several other promulgations in areas of unrest have followed. Giving a course in Libya is like walking across a firing line, yet we have presented five courses in this state. One of the courses I participated in was in Tripoli, the capital of Libya, in December 2012.

I had the worst food poisoning in Sudan, but the pleasure of presenting the course helped me overcome all of my discomfort. The smile on the face of Diaa Ageib, MD, FRCS, the Chair of ATLS in Sudan, at the certificate distribution told the whole story of this successful program.

Promulgating the course in Egypt at the peak of unrest was a memorable experience because of the demonstrations, large crowds, and the people. On our way to the airport, thousands of demonstrators were in the street playing music and singing. The crowd blocked us, specifically individuals who wanted to engage in a dialogue about the protest, but once they realized we were in a hurry, the protestors began to cooperate and allowed us to pass. The Chair of ATLS in Egypt, Abdelhakim Elkholy, MB, BCh (one of the greatest and most humble men I have met in my life), decided to take me to the airport—a trip that should require 90 minutes, but took us seven hours because of the crowd. Needless to say, I missed my flight. Today, Egypt’s program is one of the best in the region.

A Saudi citizen who goes to Iran can be subject to an investigation and could face the risk of detention. Nonetheless, bringing ATLS to Iran is one of my fondest memories. Visiting historical places and encountering the rich culture together with tasting delicious Iranian native food made this trip unforgettable. I am grateful to Prof. Khalil Ali Zadeh and Majid Sabahi, MD, who made the course a success.

We were fortunate to start ATLS in Syria before the war, but when I was there for the second course to supervise a course director candidate, he came to my room in the middle of the night terrified because a bomb exploded next to his house, and his wife had called him to ask that he return home immediately. We were in Hama, and his family was in Damascus, which is a three-and-a-half hour drive. From then on, the students were distracted by the war that was literally in their backyards. Fortunately, ATLS instruction continued despite these challenges, and its principles have been applied during the war, resulting in many saved lives. The Syrian group is like no other I have met. Their bravery and determination to continue their involvement with the ATLS family, despite the danger they place themselves in during their travel through hostile areas, is inspiring.

Ahmad Ghazal, MD, shared stories of managing victims of war in the Syrian city of Aleppo and the daily disaster experience they endured. One of the stories he shared was about a couple—a wounded husband, who, shot by a sniper, created a barrier with his body to save his wife’s life. He asked his wife to leave him alone and run for her life, but she did not leave him. She stayed with him and waited until dark, when she was able to pull her husband to where she was hiding. Despite the hours of waiting, both couples survived. A book is necessary to completely relate this experience.

Working with Dr. Abi-Saad, Chair of ATLS in Lebanon and the incoming Region 17 Chief, is an honor, not just because Dr. Abi-Saad is a well-known surgeon in Lebanon and the region, but because his calm personality, wisdom, and words of encouragement make you forget all the difficulties that exist in the region.

Watching the presentation of Abdulah Alharthi, MD, FRCSC, CBGS, Chair of ATLS in Oman, is an event nobody should miss. He showed us what you could achieve while being relaxed and smiling. He leads a great program and is proud to show beautiful Oman to all who come and visit.

When visiting Nigeria, we were always escorted by two military jeeps. Terror organizations had dramatically intensified their activities in the region, and in late 2010, during one horrific week, more than 700 people were killed. A release from University of California, Los Angeles–National University of Singapore Executive MBA program warns U.S. citizens of the dangers of travel to Nigeria. Watching the soldiers with their fingers on the trigger of a machine gun makes you mindful of the danger that may be present, but we felt safe with Nanda Nwawa, MD, Coordinator of the Nigerian Chapter of ATLS.

Mahmoud Odat, MD, FACS, Chair of ATLS in Jordan, did a spectacular job of coordinating the course. Dr. Odat was involved in every small detail of course preparation, from receiving his guests at the airport to making sure they arrived safely at the hotel. Dr. Odat also provided detailed guidance regarding the course, ensuring all students, faculty, and course directors had clear expectations. Additionally, he provided exposure to Jordan’s history, food, and culture, making participants feel like royalty, despite the fact that it is a developing country.

ATLS in Region 17 today

Today, ATLS is offered in more than 15 countries in Region 17, making it one of the fastest-growing regions within the overall program. The growth in this region has been made possible with the help of dedicated health care professionals such as Wesam Abuznadah, MD, MB, ChB, FACS, FRCSC, a notable role model for students, Region Course Educator, and a member of the Senior Educator Advisory Board.

The Course Coordinators ensure the unwavering quality and precision of the courses. Without these coordinators, the program would not exist. I want to extend my thanks to our Regional Coordinator, Vilma Cabading, who works relentlessly and nonstop to attend to all the details involved in presenting the course throughout Region 17.

Thank you to all our Regional Coordinators and Course Educators, Course Directors, and excellent instructors, with special thanks to Wael Taha, MD; Hussein Alkholani, MD, FACS from the Saudi Chapter; Jamal Saleh, MB, BCh, FRCSI, from Bahrain; Hassan Althani, MB, Bch, FRCSC, FRCS, CABS, Chair of the Qatar Chapter; and Faisal Alghanim, MD, FRCS, Course Director from Kuwait.

In 2017, we celebrated the 25th anniversary of the Saudi Arabian program. I remember that when we celebrated our fifth-year anniversary in 1997, I was able to convince the crown prince to recognize our team. We were a small group then, and we distributed watches with the ATLS logo to all the instructors. To bring this full circle, my son had an incident that caused partial airway obstruction and was rushed to the emergency room when I was out of town. My wife was relieved when she saw that the health care professional who looked after him and saved his life was wearing an ATLS watch.

ATLS is not merely a course—it is a movement of change in trauma care. The introduction of ATLS into a new country not only saves lives, it also sharpens the focus on trauma care. The ATLS course opened our eyes to the forgotten disease of trauma. We watched a movement of change that included trauma prevention initiatives, the introduction of other trauma courses, and the desire to start a trauma system.

*Friedman U. Almost half of Syria’s population has been uprooted. August 30, 2014. The Atlantic. Available at: www.theatlantic.com/international/archive/2014/08/half-of-syrias-population-is-displaced/379407/. Accessed January 22, 2018.