In 1422, France saw the succession of King Charles VII and declared the words ‘Le roi est mort, vive le roi!’ (The king is dead, long live the king). Since that day, the phrase has represented the idea of continuity despite inevitable change.
This guiding principle can be applied to the Advanced Trauma Life Support (ATLS®) course from the American College of Surgeons. Its 10th edition has arrived nearly 40 years after it was first launched in the United States. However, whether the ATLS course is relevant or desirable has been a matter of debate for decades (Davis, 2005; Driscoll and Wardope, 2005; Nolan, 2005; Wiles, 2015).
The fact that the course is effectively the only show in town in many parts of the world is not in dispute. Its virtual monopoly, and its arguably North American perspective, may or may not have stifled the growth of local solutions. Discussions about its fitness for purpose and the appropriateness of its claim to be ‘advanced’ continue unabated (Wiles, 2015).
Not surprisingly, the most hesitation and doubt about the value of ATLS is expressed from the parts of the world which have the most advanced healthcare systems. After all, ATLS was developed for the most inexperienced service providers and may not be suitable for more developed providers.
However, ATLS remains a major influence in the world. To its credit, it has introduced a standardised approach and language of ‘primary’ and ‘secondary’ survey, enabling participants of all levels of experience to feel confident.
Equally, it has drawn much criticism; in particular, its slow updates, expense, and prescriptive approach. Due to the focus on ATLS training in many parts of the world with less developed health care, invidiously perhaps, their trauma systems may not yet have emerged to the next level as a result of the lack of indigenous solutions beyond the ‘golden hour’, as this remains the main subject of ATLS.
Many service providers who attend the course enjoy it. They find ATLS gives them confidence and an opportunity to join networks. However, after 40 years of international implementation and with currently over 13 000 trainees every year, the fact that the jury is still out regarding its clinical and survival benefits is cause for reflection.
With the cost of the course at nearly $500 USD and having to regularly recertify may represent a low-yield expensive investment.
Other options to gain trauma care qualifications exist: notably the European Trauma Course (ETC); National Emergency Life Support (NELS); Emergency Trauma Management (ETM) Course; Trauma Master Class; Advanced Trauma and Critical Care Course (ATACC). Those preparing for the Diploma in Immediate Medical Care (IMC) examination and attending the Pre-Hospital Emergency Care (PHEC) course gain comparable training. Arguably, a lack of indigenous resources and substantial influence wielded by the American College of Surgeons in favour of ATLS might have disadvantaged the promotion of alternatives over the years.
While some journal editorials have recommended a move away from ATLS, in the modified words of Mark Twain: the news of its death are greatly exaggerated.
This comment briefly reviews the history, achievements, doctrine and points of interest pertaining to ATLS.
History and principles
The legend of ATLS is well known. Created by James K Styner in 1976, it would implement a standardised approach to managing trauma. The idea was spun from a personal experience after a plane crash severely injured his family and, at the time, emergency medical care was lacking.
Back then, the logic of ATLS was impeccable and elegant: anticipate, identify and correct the life-threatening effects of injury in a focused and unwavering manner.
The simplicity and replicability of the primary and secondary survey approach were timely as new objective tools for patient assessment, such as the Glasgow Coma Score and Injury Severity Score, were already arriving in the mid-1970s.
ATLS also brought into the surgical domain the approach successfully adopted by the American Heart Association's Advanced Cardiac Life Support (ACLS) course. At this time, R Adams Cowley was restating the lessons learned by the French in World War I about the ‘golden hour’ and gaining political support for trauma centres.
However, current standards of evidence-based medicine were not widely practised; therefore the clinical evidence in favour of ATLS would not meet today's expectations.
Fast-forward 40 years and the experience of trauma surgeons from war-ravaged parts of the world bore testimony to the lack of local solutions for training and practice of trauma care. ATLS continues to be at the forefront of the solution.
While the impact of ATLS training on the knowledge of participants attending the course is undeniable (Gautam and Heyworth, 1994; 1995; Søride, 2008; Lo and Lee, 2014; AbuZidan 2016), clinical benefits remain unproven. Anecdotally, those who have attended the ATLS and alternative courses find the latter just as good, or better.
With the advent of various clinical specialties such as acute surgery and acute medicine, the scientific principles aimed at acute injury and illness care across the entire chain of survival are widely practised. This includes: bringing patients to the appropriate facility alive; keeping the patients alive until definitive interventions are made; and helping patients return to health. ATLS has struggled to rapidly update in response to medical advancements, notably in: circulation and bleeding; volumes and purpose of IV fluids; the inclusion of tranexamic acid; and prioritisation of managing severe bleeding alongside the airway.
Achievements
A major strength of the ATLS is its impeccable consistency. Instructors are carefully selected, trained and encouraged to leave aside their personal perspectives and put forward the core messages of the course. Demonstrating a proficiency in the ‘ATLS-way’ is essential for the learner to gain the certificate and the recertification required on a regular basis.
Over the years, new editions of the ATLS course have heralded changes such as online remote learning in the most recent 10th edition, which may help it to survive in the digital age. However, the ATLS is available only to doctors, although the clinical space is widely shared by doctors and non-medically qualified colleagues—this is considered a shortcoming.
What's new?
According to the publicly available sources (ATLS, 2018; Long, 2018; Woo, 2018), the latest version of ATLS comes into line with widely practised protocols for massive haemorrhage, including the use of tranexamic acid. The following are further amended protocols:
Conclusion
To many supporters of ATLS training, 10th edition changes will have come not a day too soon. This edition will bring it in line with widespread evidence-based practice from around the world. To the critics, ATLS is still playing catch-up and perhaps delivering too little fizz for its buck.
Whether this edition is indeed a worthy successor to a great legacy—only time will tell. As more and more care providers and countries seek to achieve better standards of service, ATLS is no longer the only available option and the search for the next king who lives as long may have only just begun.