In 1976, the orthopaedic surgeon and pilot, Dr Jim Styner, was flying his wife and four children over rural Nebraska, when storm clouds began to gather. Lowering his altitude, Styner lost control of the aircraft, which impacted with a row of trees before crashing to the ground. His wife was instantly killed, three of his children lost consciousness and Styner himself suffered chest trauma and a fractured orbit in his skull.
With the help of his eldest son, Styner performed basic first aid on the three younger children, before finally hitchhiking to the nearest hospital – a small, out of the way facility, with no emergency room and a skeleton staff with little-to-no trauma training. Once inside, the care that Styner and his family received was so appalling that, though severely injured, Styner had to physically intercede to prevent the doctors from treating his unconscious children. Being discharged from the hospital, Styner later said, was like “coming out of a hostile hell into civilisation”.
Styner’s affecting experience led to the formation of the Advanced Trauma Life Support (ATLS) course, now a global programme, established to teach doctors how to manage severely injured patients. As Stephen Bush, chair of the ATLS European Association, explains, before Styner’s intervention, care for trauma patients was severely lacking a sense of urgency. “The clinical approach was to take a history, examine the patient, investigate, come to a differential diagnosis, and then treat,” he says. “But with severely injured patients, you haven’t got that luxury – you’ve got to assess and treat simultaneously. In that first initial phase, it doesn’t matter what’s obstructing the airway, open it. It doesn’t matter why the patient’s hypoxic, give them oxygen.” This “goal-directed care” approach, Bush explains, offers a structure for “assessing a patient from top to toe (airway, breathing, circulation, disability and exposure) in a very rapid but focused way, to identify the threat to life and treat them simultaneously”. That, in essence, is the principle of the ATLS course.
Earlier this year, the first non-doctor qualified from the instructor course – an indication of just how far ATLS continue to strive to make the basics of trauma care accessible to all. As Bush notes, “the course is deliberately low-tech so it can be taught with any small number of devices and materials” and focuses on instructing individuals to “manage the patient on their own”, in order to make ATLS adaptable around the globe. As Bush says, citing Professor Chris Moran, the national clinical director for trauma to the NHS: “standardisation gives you resilience”. “It's a really powerful message”, Bush adds, “because once you’ve got that training level, the individuals know [what they’re doing]. It’s just a matter of slotting into a very, very robust template of action.”
Introducing trauma training
In the UK, ATLS procedures tend to be integrated into professional trauma teams and used in conjunction with the latest medical technology – but that hasn’t always been the case. “When ATLS came to the UK, which was in the early 1980s, things were very different,” Bush explains. “We didn't have trauma systems, we didn’t have trauma networks and we certainly didn't have major trauma centres.” Between 1992 and 2010, a series of reports from national bodies, including the Royal College of Surgeons, the British Orthopaedic Society, and the National Audit Offices, revealed the extent to which trauma care in the UK required an overhaul. “As a nation, we weren’t where we needed to be in the 1990s and the early 2000s,” says Bush. “There were pockets of really excellent care, but there was real inconsistency across the country.” In 2010, the first major trauma centres were established in London, with further regional centres opening across the country from 2012. Astonishingly, the integration of the major trauma network was relatively seamless. “The major trauma centres have to have consultants 24/7 to receive patients, and they have to have a certain level of infrastructure to be present and ready,” Bush says. “But the actual clinical skills were already in existence. It was just a matter of organising it. And it’s been a game changer.”
As well as being staffed by ATLS-trained practitioners, trauma centres in the UK also have immediate access to life-saving technologies. “In most major trauma centres, we have a CT scan that is immediately available – if not actually within the emergency department, then [directly] adjacent to it,” says Bush. “Having access to CT makes a big difference. We do major trauma CTs from the top of the head to the mid-thigh – so, in other words, you're scanning every part of the patient that could potentially cause a threat to life. That’s probably been the single biggest technological change to trauma in the past 20 years.”
In conjunction with CT scanning, “the next biggest thing for definitive trauma management”, Bush explains, is “interventional radiology”. Traditionally, open procedures to prevent pelvic or abdominal bleeding involve packing the pelvis with swabs. But with interventional radiology, “radiologists can find the vessels that are bleeding using image intensification, and can embolise those vessels by putting [embolic agents] down the catheter that expand and block the blood vessels,” explains Bush. “That process is called angioembolisation.”
The big message that came out of the trauma reports in the 1990s and early 2000s was that bleeding often went unrecognised and untreated. “Now there is a much greater awareness that if somebody is bleeding, we have to do something about it, and just pouring in blood and blood products is not the answer,” says Bush. He offers an analogy to illustrate the problem: “You’ve run yourself a relaxing bath, the temperature of the water is just right, you’ve got rose petals in there, everything is perfect. And then, horror of horrors, your toe catches the chain and pulls the plug out. What is your first instinctive reaction? Well, you put the plug back in. You don't turn the taps on and think about maybe putting the plug back in at some point. That’s the paradigm that has changed with shock: we have to stop the bleeding”.
The trouble with trauma
Nevertheless, as a study published in Journal of Surgery and Anesthesia noted, trauma continues to remain the leading cause of morbidity and mortality in developed countries. In recent years, surgeons and researchers in the field have sought to address this statistic by developing hybrid operating suites that bring together novel technologies with advances in therapeutic angiographic techniques. One such facility is the RAPTOR (resuscitation with angiography, percutaneous techniques and operative repair) suite at the Foothills Medical Centre, Calgary, Alberta in Canada, where surgeons have been comparing outcomes between truly simultaneous and rapid serial procedures since 2013.
While the financial cost of specialised suites like these remains high, a RAPTOR study from 2022 reveals that “patients who require nearly concurrent emergent percutaneous and open procedures to arrest ongoing haemorrhage may be saved by this resource”. Whether a fully integrated suite, or simply the provision of imaging technologies adjacent to the surgical space, it seems likely that hybrid operating rooms will continue to be a decisive factor in shaping the future of trauma care.
Moving forward, Bush predicts a growing interest in developing artificial blood products. “I think there will be a step change when we’ve got something that isn’t reliant on blood donation,” he says. But in most areas of trauma care, he believes improvements will be much more iterative. “I think we’ll continue to refine our protocols and how we identify what patients need which particular care processes,” he says. “Interventional radiology will continue to have greater input into care pathways for patients, and I also think there will be a greater focus on rehab. We know that for every patient that dies, three patients suffer life changing injuries, and we know that rehab makes a big difference to their quality of life and what they are finally able to do.”
Trauma care has come a long way since Styner’s tragic experience in 1976, and ATLS has played a decisive role in shaping that trajectory. Standardising trauma care procedures – and making those standards accessible and exportable, irrespective of a country’s healthcare or economic status – has meant that, wherever they are in the world, severely injured patients can expect a certain level of primary care. How technology will continue to build on those standards remains the next big question in the field of trauma; our lives just might depend on it.
