The COT at 100: Evolution and Promulgation of ATLS and Surgical Skills Training

Highlights

• Describes the development of the ATLS Course and summarizes its global expansion 
• Identifies future content topics for the ATLS Course, including the effects of social determinants of health on trauma care
• Summarizes the evolution of COT surgical skills training courses, including ATOM, ASSET, and BEST

Since its founding in 1913, the American College of Surgeons (ACS) has recognized that education and skills training are paramount to quality care. The ACS Committee on Trauma (COT) has adhered to this principle through a range of programs designed to ensure necessary and effective care for the injured patient.

This article highlights some of the training courses that the ACS COT has promulgated over the past 100 years, starting with the Advanced Trauma Life Support^® (ATLS^®) Program.

ATLS

Since its inception in 1978, ATLS has been the model for trauma education for all levels of providers and has set the standard as the premier educational offering of the COT. ATLS provides physicians and other healthcare professionals with a concise and structured approach to assess and manage patients with multiple injuries.

As the care for the injured patient has evolved over the past 40 years, the basic tenets of ATLS remain relevant. These include promptly identifying injury, prioritizing and addressing immediate life threats, performing an efficient secondary survey when possible, arranging for access to definitive care, and communicating in a standardized fashion. At the time that ATLS was conceived, standards for the evaluation and management of injured patients were nonexistent, only a few cities had organized trauma centers, and state trauma systems had yet to be developed.

An Innovative Approach to Avoiding Tragic Outcomes

The need for a course to teach initial trauma care was realized by James K. Styner, MD, FACS, after he and his children survived a tragic plane crash flying home to Lincoln, NE. His wife died at the scene. Dr. Styner extricated his four children from the aircraft and searched for help. They were eventually taken to a rural local hospital. The covering general practitioners at the hospital had little experience in managing patients with multiple injuries. They prioritized obtaining skull x-rays and suturing lacerations over a comprehensive assessment of the children.

Reflecting on this event, Dr. Styner questioned the state of early injury care, saying, “When I can provide better care in the field with limited resources than my children and I received at the primary facility, there is something wrong with the system and the system has to change.” Ronald Craig, MD, a family physician and friend of Dr. Styner, became his sounding board, noting, “You have to train them before you can blame them.”

This experience and Dr. Craig’s advice became the impetus for the development of a course to teach the basics of trauma care. Nurses from the Lincoln Mobile Heart Team, including Irvene Collicott, RN (née Hughes), who in 1982 became the Program Manager for ATLS, were essential to the development of the course. The ABCDE (airway, breathing, circulation, disability, and exposure) algorithm was developed by the consensus of content experts (Table 1). ATLS focused on trauma as a surgical disease and aimed at identifying and treating the greatest life threat first. It was presumed this approach would result in vastly improved patient outcomes.

With the help of the Lincoln Medical Education Foundation and Southeast Nebraska Emergency Medical Services, a pilot ATLS course was developed. At the invitation of then-COT Chair C. Thomas “Tommy” Thompson, MD, FACS, and Paul E. “Skip” Collicott, MD, FACS, a vascular surgeon from Lincoln, NE, subsequently presented the course to the leadership at the annual COT meeting in spring 1979. Later that year, an inaugural course for COT region chiefs took place in Lincoln, NE.

The ACS Board of Regents approved the course in 1980, and agreed to invest $80,000 to develop course materials. The course was disseminated nationally through the infrastructure of the Regional COT Committees beginning in 1980. The first courses outside the US took place in 1981 in Vancouver, BC, and Toronto, ON. The ATLS Subcommittee was formed to provide oversight and support enhancement and advancement of the new course. Within 2 years, ATLS became the standard for the initial evaluation and management of patients with trauma in the US and Canada.

Going Global

The ATLS Course continued to expand within North America in the early and mid-1980s. As the course became more popular, healthcare providers in an increasing number of countries requested the opportunity to participate. Much effort was required to ensure uniformity of the course regardless of location. Mexico was added to the ATLS family in 1986. Several countries in South America soon after expressed interest in participating in the program.

ATLS expanded to Europe through the Royal College of Surgeons, and to Australia through the Royal Australasian College of Surgeons in 1988. With growing interest in ATLS outside of North America, the COT recognized that to have a more significant impact on trauma worldwide, global regional leadership was necessary. A global ATLS committee was formed and met jointly at the annual ACS Clinical Congress.

Latin America was the first area to formalize a structure of regional committees as Region 14. Others followed suit: Region 15 encompassed Europe and Southern Africa, and Region 16 was composed of Australia and Asia. In 2011, Region 17 was established to serve the Middle East and North Africa.

The promulgation process was subsequently adopted under ATLS International Chair John B. Kortbeek, MD, FACS (2009–2014), with the support of COT Chair John Fildes, MD, FACS (2006–2010). Dr. Kortbeek proposed heavily relying on the regional structure to decrease the cost of local course-site development. This approach decreased the number of faculty traveling from the US and the need for stakeholders to travel to the US for training. Subsequent ATLS International Chairs Karen J. Brasel, MD, FACS (2014–2018), and Sharon M. Henry, MD, FACS (2018–2022), expanded its reach.

A strong global regional structure has given a voice to the global ATLS family in matters of policy and content updates. ATLS has now been translated into 10 languages: Spanish, Portuguese, French, German, Greek, Indonesian, Italian, Mandarin, Mongolian, and Romanian. At present, ATLS programs have been offered in 86 countries, providing a common “language” among multidisciplinary trauma providers (Figure 1).

More than half of the courses presented annually take place outside the US and Canada, and the global community participates in all aspects of course design, revision, and oversight. The combined efforts of committed leaders from around the world have successfully advanced the quality of the course by ensuring that course content is relevant in all countries and systems that possess at least a minimal degree of infrastructure to support trauma care. The collaborative efforts also created the goodwill necessary to encourage and promote further global expansion and trauma system development.

Ongoing Refinements

ATLS for medical students was created in 1999 in the form of a Trauma Evaluation and Management (TEAM) course to address the trauma training gap in medical schools. This course can be modified to meet local needs and can function as an introduction to trauma training in regions that lack the infrastructure to support full ATLS promulgation.

ATLS has progressed through the years (from its origins of didactic lectures and slides), embracing and adapting to changes in technology as well as developments in educational theory and simulation. As scientific evidence has evolved to influence practice, new information and consensus-based updates are added to the content through revision processes that occur approximately every 4 years.

The influence of educators to enhance the learning experience, as well as promoting a more open and adult learner-oriented feedback, has refined delivery of the course and elevated the educational experience. The role of the educators in program oversight was formalized with the development of the Senior Educator Advisory Board in 2010. The development of the ATLS app also has allowed the program to adopt new platforms.

The 10th edition of the ATLS Course launched in 2017–2018 and was accompanied by a mobile-learning platform. The COVID-19 pandemic necessitated that we take advantage of technology to reach not only places that are geographically remote, but also sites that, pre-COVID, could train large numbers of learners in person. The pandemic required that we use technology not only for basic meetings, but also to provide effective and interactive education.

The use of mobile ATLS (mATLS) online modules has dramatically increased during the pandemic as more sites are employing the mATLS or hybrid courses as their primary program. Other sites are taking advantage of the online modules to begin training learners until they can resume in-person courses. The next step in education for ATLS may be incorporating enhanced reality platforms to augment aspects of the course.

The Future of ATLS

In the future, ATLS should more fully embrace the global issues that affect our patients but are not part of the traditional core content, adding information on:

• Injury and violence prevention
• Trauma-informed care in the emergency setting
• Issues related to trauma recovery, including posttraumatic stress and postintensive care syndromes
• Principles of palliative care in the emergency setting
• The effects of social determinants of health on trauma care

Although ATLS was developed to address life-threatening physical injuries in emergency settings, it cannot exist in a vacuum—nor can our practitioners. ATLS, as the COT’s prototype educational offering, must provide learners with the tools they need to be effective advocates for policies that help our patients survive not just physical trauma, but all the antecedents and sequelae of that trauma so that it meets the goal of our new Global Trauma Education Fund: Trauma Knowledge for All.

ATLS Leadership

James K. Styner, MD, FACS, author, developer, pioneer

ATLS Chairs

• Paul E. Collicott, MD, FACS (1978–1987)
• Max L. Ramenofsky, MD, FACS (1987–1992)
• Brent E. Krantz, MD, FACS (1992–1996)
• Richard M. Bell, MD, FACS (1996–1999)
• Steven N. Parks, MD, FACS (1999–2003)
• Christoph R. Kaufmann, MD, FACS (2003–2007)
• John B. Kortbeek, MD, FACS (2007–2009)
• Karen J. Brasel, MD, FACS (2009–2014)
• Sharon M. Henry, MD, FACS (2014–2018)
• Kimberly T. Joseph, MD, FACS (2018–2022)
• John P. Sutyak, MD, FACS (2022–present)

International ATLS Course Directors

• Christoph R. Kaufmann, MD, FACS (2007–2009)
• John B. Kortbeek, MD, FACS (2009–2014)

Global ATLS Course Directors

• Karen J. Brasel, MD, FACS (2014–2018)
• Sharon M. Henry, MD, FACS (2018–2022)
• Danny Westerband, MD, FACS (2022–present)

ATOM Course Directors

• Lenworth M. Jacobs Jr., MD, MPH, FACS (2007–2010)
• Sharon M. Henry, MD, FACS (2010–2014)
• Ronald I. Gross, MD, FACS (2014–2018)
• Jody M. Kaban, MD, FACS (2018–present)

ASSET Course Directors

• Mark W. Bowyer, MD, FACS (2008–2018)
• Eric J. Kuncir, MD, FACS (2018–2021)
• Daniel J. Grabo, MD, FACS (2021–present)

BEST Course Director

• Megan Brenner, MD, FACS (2016–present)

PAST CHAIRS

Ad Hoc Committee on Surgical Skills

• Fred A. Luchette, MD, FACS (2005–2010)
• Mark W. Bowyer, MD, FACS (2010–2018)

Surgical Skills Committee

• Neil G. Parry, MD, FACS (2018–present)

Surgical Skills Training

With diminishing operative experiences available in trauma surgery, the COT Executive Committee recognized the need for a surgical skills course to provide surgeons with the proper skillset to treat complex, multiply injured patients.

The first official record of the committee’s intention to develop such a course can be found in the 2001 COT annual report, where it is listed as one of the objectives for the Subcommittee on Education. In 2003, COT Chair J. Wayne Meredith, MD, FACS, MCCM, created a task force under the oversight of Demetrios Demetriades, MD, PhD, FACS, Chair of the Subcommittee on Education. Lawrence N. Diebel, MD, FACS, who had developed a cadaver-based operative trauma course in Detroit, MI, was asked to lead this task force with assistance from Gregory J. Jurkovich, MD, FACS. The panel was charged with planning and executing an ACS COT-sponsored operative skills course. Over the next 3 years, the task force developed the Operative Exposure course, a cadaver-based course centered on 10 lifesaving procedures. This course later became known as the Anatomically Based Surgery for Trauma Course and was a precursor to the Advanced Surgical Skills for Exposure in Trauma (ASSET) course established in 2010.

The Advanced Trauma Operative Management (ATOM^®) course was developed by Lenworth M. Jacobs Jr., MD, MPH, FACS, in 1998, with the first course offered in 2001. Leveraging the efforts of Dr. Diebel’s task force, the COT formed an Ad Hoc Committee on Surgical Skills, with Fred A. Luchette, MD, FACS, appointed as first chair. Under his leadership, ATOM formally transitioned as a COT educational course.

It subsequently became clear that trauma surgeons would require both a broad skill set in open surgery and novel endovascular hemorrhage control techniques. With the increasing use of the resuscitative endovascular balloon occlusion of the aorta (REBOA) technique, the COT Executive Committee determined it could help formalize and promulgate training for appropriate practitioners. In 2016, the Basic Endovascular Skills for Trauma (BEST) course, developed by Megan Brenner, MD, FACS, at the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, came under the umbrella of the Surgical Skills Committee of the COT.

ATOM

The idea for a standardized operative simulation course was inspired by Dr. Jacobs’s experience with the Definitive Surgical Trauma Care (DSTC) course in South Africa. Dr. Jacobs also drew inspiration from simulation training of aircraft pilots.

The goal of the ATOM course was to include common injuries that every trauma surgeon is likely to encounter. The course was developed with a series of trial runs between 1998 and 2000, during which actual clinical cases in the operating room were recreated to establish what was reproducible and tolerable for the porcine model. Karyl J. Burns, RN, PhD, a medical educator, was essential in establishing valid educational methods and measurements in the course, whereas trauma fellows helped standardize everything from the clinical scenarios featuring a series of injuries to the lectures and test questions.

The first course was offered in June 2001 at Hartford Hospital, University of Connecticut, and over the next 2 years care was taken to collect data from residents, fellows, and attending surgeons who participated in the course. A panel of 20 national experts who had taken the course was established to further evaluate and enhance the educational goals and requirements of the ATOM course. Dr. Jacobs, Ronald I. Gross, MD, FACS, and Stephen S. Luk, MD, FACS, subsequently edited the textbook. The COT eventually embraced ATOM in a 5-year transition plan for the Ad Hoc Surgical Skills Committee to oversee the course in 2007, with Dr. Jacobs as the first ATOM Course Director.

Dr. Jacobs always believed that the ATOM course had the potential to have a long-lasting impact. His most memorable experience of developing the course was seeing the increase in self-confidence among residents and fellows who completed the course. The global development of the course was also meaningful. In his words, “I have learned more from teaching than I have taught.”

ASSET

With the creation of the Ad Hoc Committee on Surgical Skills in 2005, work continued to implement an in-house COT-sponsored high-quality, cadaveric, anatomically based trauma course. Under the leadership of Dr. Luchette as Chair of the Ad Hoc Committee on Surgical Skills and the addition of then-US Air Force State Chair Colonel Mark W. Bowyer, MD, FACS, the committee reviewed all existent cadaver-based exposure courses, including the International Association for Trauma and Intensive Care’s DSTC course and the Definitive Surgical Trauma Skills course, developed jointly by the Royal College of Surgeons of England and the Uniformed Services University of Health Sciences (USUHS), as well as the US military’s Emergency War Surgery Course to prepare surgeons for combat.

Over the next year-and-a-half, an extensive list of life- and limb-saving skills that were considered essential for all surgeons caring for victims of trauma were developed, and a modified Delphi approach was enlisted to finalize the list of skills that should be included in a trauma exposure course. The final skills selected included exposure and control of every major blood vessel from the chin to the toes, as well as thoracotomies, fasciotomies, and intra-abdominal damage-control procedures.

The course consists of a brief case in the lab highlighting specific injuries, with interactive discussion of next steps followed by a few slides of relevant anatomy and a brief video demonstrating the desired skill. After each segment of the presentation, students then are expected to perform the skill in a time-pressured manner with the help of faculty.

The beta ASSET course, initially the Anatomically Based Surgery for Trauma course, was conducted March 11, 2008, in Washington, DC, at USUHS. Further beta courses then were offered across the US, and the name of the course was officially changed to ASSET. With the ASSET manual, written tests, policies, and procedures, as well as lab slides finalized, the ASSET course officially was launched at the March 2010 COT meeting. The first global course took place in Toronto in August 2010. The ASSET course curricula have undergone rigorous validation, and studies to date have shown that participants show marked improvement over baseline in selected vascular exposures after taking the course.

Dr. Bowyer became the second Chair of the Ad Hoc Committee on Surgical Skills (2010–2018) and served as a special consultant for global courses (2019–2021). Under his leadership, the ASSET course was promulgated to more than 180 sites in 19 countries.

With the help of more than 120 trauma surgeons, the original manual has been updated and revised to include skills such as REBOA, cricothyroidotomy, and vascular shunting in the standard course. In addition, the revised manual will include skills for rural, humanitarian, and military surgeons, with chapters on damage-control ophthalmology, neurosurgery, orthopaedics, cesarean section, and management of postpartum hemorrhage, amputations, and burns.

Since 2017, the US military, under Dr. Bowyer’s leadership, has been working to adapt and expand the original ASSET course to better meet the needs of military surgeons who may be required to perform a variety of skills not typically performed by general surgeons, particularly when subspecialists are unavailable. This effort has led to the development of an expanded ASSET course called ASSET+ (ASSET Plus), which has been developed and fielded through the cooperation of the COT, USUHS, and the Military Health System Strategic Partnership of the ACS. ASSET+ will replace the Emergency War Surgery Course for all active-duty surgeons. The German, Swedish, Hungarian, and Estonian militaries also have incorporated the ASSET course into combat-readiness training for their surgeons.

BEST

As trauma surgeons continued to look for ways to manage patients with exsanguinating, noncompressible torso hemorrhage, and in 2009 an increasing number of clinical reports emerged about the use of REBOA. At the same time, Dr. Brenner had just finished her trauma fellowship at the R Adams Cowley Shock Trauma Center, where trauma leaders, too, were very interested in the clinical applications and indications of endovascular hemorrhage control. After completing endovascular and vascular fellowships, she realized that there was a lack of succinct REBOA techniques courses for civilian trauma surgeons. With support from Thomas M. Scalea, MD, FACS, Dr. Brenner developed the course as a natural progression from their shared clinical experience. She routinely incorporated clinical lessons into the course using simulation modules that included perfused cadavers.

The first BEST course for the surgical faculty at Shock Trauma took place in 2013. In 2014, the course was opened to the surgical community and, because of wide interest, one course was offered each month for several years. In 2015, Dr. Brenner was selected as one of the first participants in the COT’s Future Trauma Leaders program. In 2016, as technology was evolving rapidly for REBOA, BEST officially joined the COT and the Surgical Skills Committee.

The Future

The Surgical Skills Committee of the COT continues to promote and advance the care of the injured patient with high-quality, contemporary surgical courses that can be adapted for an array of audiences and cultures. The committee members look forward to exploring new educational approaches including simulation and virtual reality with the goal of ensuring the best possible skills training for surgeons who provide care to patients with life-threatening injuries. To ensure that surgical residency programs around the globe can incorporate these critical skills training courses, the courses are widely available for practicing surgeons, and are readily available as just-in-time training for surgeons preparing to deploy into combat zones.

Together ATLS, ATOM, ASSET, and BEST represent four of the COT’s many educational course offerings. To date, more than 1,214 ATOM courses, 1,043 ASSET courses, and 144 BEST courses have been offered throughout the world, and more than 1 million providers have been trained in ATLS worldwide (Table 2).

Acknowledgements

The authors acknowledge the contributions of Mark Bowyer, MD, FACS, Neil Parry, MD, FACS, Jody Kaban, MD, FACS, Eric Kuncir, MD, FACS, Megan Brenner, MD, MS, FACS, and Jean Clemency, Administrative Director, Division of Research and Optimal Patient Care–Trauma Programs, to the development of this article.

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Major Rachel Russo is a US Air Force trauma surgeon, assistant professor of surgery, University of California-Davis, and assistant professor of surgery, the USUHS, Bethesda, MD. She is the Military Future Trauma Leader, ACS COT, and Vice-Chair, Air Force COT.