When passion and curiosity collide: The beginnings of the ATLS program

More than 40 years ago on a cold February night, the family of orthopaedic surgeon James K. Styner, MD, FACS, was in an airplane crash. His wife, Charlene, was killed instantly, and Dr. Styner and his four children were injured—three critically and one with minor injuries. The accident and the treatment his family received sparked a flame in Dr. Styner and his colleagues, resulting in what eventually would become the Advanced Trauma Life Support^® (ATLS^®) program. Little did these pioneers know that the protocols drafted around the dining room table of Ronald Craig, MD, a family medicine physician in Lincoln, NE, would go on to be taught worldwide in 86 countries and taught to more than 1 million providers, including physicians and physician extenders.

An education in ATLS

In 2014, I became the trauma outreach and injury prevention coordinator at Bryan Medical Center, Lincoln, NE. I had previously worked as an intensive care unit (ICU) nurse and have always been proud of our organization and the care that we provide to our patients. In the coordinator role, I serve not only as the ATLS Course Coordinator, but I am also fortunate enough to travel to our rural access hospitals and emergency medical services (EMS) squads to provide training. These experiences allow me to connect with health care providers not only to educate them, but also to share Bryan Medical Center’s proud history as the birthplace of ATLS.

In 2015, I became more curious about Dr. Styner and this family of whom I had spoken at every ATLS course I had facilitated, and I wanted to know more: Are Dr. Styner and his family aware of the impact that they had on the community of Lincoln and around the world?

So, the journey of seeking out Dr. Styner began. What started out as a quest to find him and to express gratitude for what he started turned out to be an even more enriching experience than I had originally anticipated. The journey led to untold stories, treasured friendships, buried memories, and the acknowledgment of what a group of community physicians from Nebraska—Louis Gogela, Sr., MD; Carlos Mota, MD; Richard Fruehling, MD, FAAFP; John Reed, MD; Glen Lau, MD; and Paul “Skip” Collicott, MD, FACS—and nurses created to improve injury care, not only for the citizens of Nebraska, but that also has saved millions of lives and changed trauma care around the globe. I have spent the last two years speaking with the originators of ATLS and visiting the American College of Surgeons (ACS) Archives, and the more my research revealed, the more I became proud of what these pioneering providers have accomplished. This article describes some of the history and untold stories of ATLS that I uncovered on this journey to learn more about Dr. Styner and his legacy.

The birth of ATLS

In 1974, Dr. Craig returned to Lincoln after being in private practice for a couple of years in Missouri. He was excited to return to Lincoln. He had completed his internship at Bryan Memorial Hospital, which led to a position at Lincoln General Hospital as the chairman of the emergency department. During a conversation I had with Dr. Craig, he stated he was in no way qualified for such a position; however, he was thankful he got the experience.

Following the plane crash on February 18, 1976, Dr. Styner continued to voice his concerns regarding the care his family received at the small critical access hospital where they were initially taken. As it happened, the Craigs and Styners attended the same church in Lincoln, and eventually Dr. Craig advised Dr. Styner to stop talking about the limited care his family received after the accident and to do something that would make a difference to other trauma survivors.

In 1977, Dr. Craig transitioned to the Lincoln Medical Education Foundation (LMEF), now known as Lincoln Medical Education Partnership (LMEP), as a member of the faculty and began working with John Upright, PhD, EdD, and Jodi Upright, RN. Dr. Upright was the executive director of LMEF at the time, and one of his roles in that position was to work with EMS to improve prehospital care in Nebraska. Ms. Upright was a nurse and a member of the Lincoln Mobile Heart Team, which provided innovative cardiac care to area patients. Together, they worked closely with Stephen Carveth, MD, FACS, a cardiac surgeon in the Lincoln community who in 1973 created an emergency dysrhythmia recognition course for the treatment of cardiac patients. This course eventually became known as Advanced Cardiac Life Support (ACLS) and is now associated with the American Heart Association. Dr. and Ms. Upright invited Dr. Craig to Chicago, IL, to attend an EMS conference, and one evening during the conference they discussed creating a course that would replicate the ACLS but for trauma patients. Dr. Craig said that the Uprights adeptly convinced him the idea was his, but in reality, the credit should go to Dr. Upright.

Dr. Craig returned to Lincoln and reached out to Dr. Styner, asking if he would like to be a part of making trauma care better in the state of Nebraska. In 1977, Dr. Craig and Dr. Styner were meeting twice a week in the dining room at the Craig home, working two to three hours at a time to develop a step-by-step guide to the early care of the trauma patient.

In June 1977, Dr. Upright asked a panel of physicians to volunteer to create an early care for the trauma patient program. In collaboration with Irvene Hughes, RN, a critical care nurse from the Lincoln Mobile Heart Team, who helped coordinate each topic, the panel would review and advise on specific material and content for the course. Ms. Hughes went on to become the first ATLS Manager for the ACS Committee on Trauma (COT).

First courses presented

The first course took place in Auburn, NE, February 11–12, 1978. The course lectures were limited to 30–45 minutes, and the target audience was the small-town physician. The second course occurred in the western Nebraska town of Scottsbluff. Dr. Craig, like Dr. Styner, was a pilot. Coincidentally, on the way to this class, Dr. Craig experienced plane trouble and made an emergency landing only 65 miles outside the city of Lincoln. With the aid of a mechanic, Dr. Craig was able to identify the problem, fix it, and get back in the air, making it to the class with time to spare.

Dr. Craig does not remember when ATLS got its name; however, he believes the course name was decided upon at the beginning of its development, as it likely made sense to follow after ACLS. ATLS was getting great reviews and the physicians participating in the program found the material worthwhile. The American Academy of Family Practice (AAFP), now known as the American Academy of Family Physicians, was initially offered the curriculum but elected not to pick it up. According to Dr. Craig, the AAFP likely considered the course not robust enough for their purposes. As word of the course spread through Nebraska, the immediate Past-Chair of the ACS COT, Robert W. Gillespie, MD, FACS, and the president of the American College of Emergency Physicians, Harris Graves, MD, FACEP, encouraged Dr. Collicott and Ms. Hughes—both of whom had taken ownership of the course—to be innovative in their enhancement of the course, because trauma was starting to be considered a surgical disease.

ACS steps in

Dr. Collicott, Past-Director of the ACS Division of Member Services and a recipient of the College’s Distinguished Service Award, arrived in Lincoln in 1973 after completing his general surgery training at the University of Washington, Seattle. Prior to surgical training, Dr. Collicott spent two years in the U.S. Air Force during the Vietnam War, and was anxious to begin his surgical career in the American heartland. By 1978, Dr. Collicott was already a recognized member of the ACS COT, and he introduced the concept of the ATLS program at the 1979 ACS COT 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.

The original funding for the course was provided by an EMS state grant, and when the ACS took over, all materials were handed over with no contract or financial agreement, according to Dr. Collicott.

The following January 1980, the ACS COT Region Chiefs were called to meet in Lincoln for their introduction to the course. At this meeting, Norman McSwain, MD, FACS, a surgeon from Louisiana, became involved in the rollout of the ATLS program. Although not a Region Chief, Dr. McSwain was invited because of his influence and knowledge of EMS. Later that year, ATLS was presented in eight additional cities: Denver, CO; San Diego, CA; Philadelphia, PA; Milwaukee, WI; Dallas, TX; Washington, DC; Newark, NJ; and Auburn, AL.

Where are they now?

When this journey started, my goal was to locate Dr. Styner. I had heard he was living in California and did my best to locate him, but instead, I was able to connect with his son, Randy. Randy and I began communicating via e-mail and quickly became friends, sharing family pictures and so on. Randy works in emergency management in California and has served his country as a U.S. Marine. Dr. Styner is living in the Philippines with his wife, Lily. I was able to communicate briefly with Lily via Facebook; however, I have not been able to communicate with Dr. Styner. Unfortunately, Dr. Styner is ill and was unable to speak to me. Randy and his siblings went to the Philippines in 2017 to visit their father, and at that point, Randy informed Dr. Styner about my research regarding the history of the course, and he even got Dr. Styner to sign Randy’s book The Light of the Moon: Life, Death and the Birth of Advanced Trauma Life Support; this was the best gift I could’ve received.

Dr. Craig and his wife remain in Lincoln in the same house in which the initial ATLS outline was written. In fact, the first time I visited Dr. Craig, he had set up an old projector and had the original ATLS slideshow for me to view. He continues to volunteer at LMEP, twice a week. Randy returned to Lincoln in September 2017 to speak at our annual trauma symposium, reconnect with old family friends, see our trauma center, and visit his mother’s final resting place. Randy, Dr. Craig, and I participated in an Eastern Association for the Surgery of Trauma Traumacast (a webcast) this past year about the birth of ATLS.

As for updates on the ATLS original faculty: Dr. Reed and Dr. Lau remain in the Lincoln community. Both are retired; however, Dr. Reed continues to work six days a week seeing wound patients. Dr. Mota and Dr. Gogela are both deceased; however, Dr. Gogela’s grandson is very active as a neurosurgeon at Bryan Trauma Center. Dr. Mota’s sons are both physicians; one is a general surgeon who also takes trauma calls at Bryan Trauma Center, and the other is an ophthalmologist. Dr. Fruehling is a primary care physician who still practices in Grand Island, NE. And, finally, Dr. Collicott enjoys the retired life with his wife Irvene Collicott, formerly Hughes, splitting his time between Lincoln and his home in Wyoming.

Bryan Memorial Hospital and Lincoln General Hospital merged in 1997 and became Bryan Medical Center. Bryan Medical Center is a 640-bed, not-for-profit, locally owned health care organization serving patients from throughout Nebraska, as well as parts of Kansas, Iowa, South Dakota, and other states in the region. The Bryan Trauma Center is an ACS Level II verified adult trauma center and was the first verified trauma center in the state of Nebraska.

The ultimate goal of each of these individuals and the medical center where ATLS launched was to improve care of the injured patient. That goal didn’t initially include the creation of a course that would become the gold standard of trauma care and save millions of lives around the world, but that is precisely what happened.

Now, as we prepare to celebrate the 40th anniversary of ATLS and the release of the 10th  Edition, we are seeing the same multidisciplinary approach to saving lives with the Stop the Bleed^® campaign—an initiative that also was inspired by a tragic event, in this case the December 2012 fatal shooting of 20 children and six teachers at Sandy Hook Elementary School in Newtown, CT, which led a handful of individuals to make a substantial change in how victims of mass casualty events are treated.